Provider Demographics
NPI:1376033308
Name:GUTIERREZ, STEPHANIE DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
Last Name:GUTIERREZ
Suffix:
Gender:F
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 E CARONDELET DR STE 235A
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3533
Practice Address - Country:US
Practice Address - Phone:520-367-1050
Practice Address - Fax:520-844-7600
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ9116363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500745920Medicaid