Provider Demographics
NPI:1295106391
Name:GUTIERREZ, LUIS CARLOS (PA-C)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:CARLOS
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W CAMPBELL AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2691
Mailing Address - Country:US
Mailing Address - Phone:623-600-4126
Mailing Address - Fax:
Practice Address - Street 1:700 W CAMPBELL AVE STE 15
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2691
Practice Address - Country:US
Practice Address - Phone:623-600-4126
Practice Address - Fax:628-412-7317
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ075466Medicaid
AZZ183106Medicare UPIN