Provider Demographics
NPI:1700242112
Name:GUTIERREZ, GUSTAVO (CPNP)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:800 S COUNTY LINE DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081
Practice Address - Country:US
Practice Address - Phone:575-824-0820
Practice Address - Fax:575-824-1021
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02890363LP0200X
TXAP129867363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48681253Medicaid
NM507110YRNDOtherMEDICARE