Provider Demographics
NPI:1336809151
Name:GUTIERREZ, LINO CARLO JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:LINO
Middle Name:CARLO JOSEPH
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FAIRWAY PARK BLVD UNIT 1012
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5148
Practice Address - Country:US
Practice Address - Phone:904-639-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered