Healthcare Provider Details

I. General information

NPI: 1427600782
Provider Name (Legal Business Name): GUSTAVO DURAZO JR. DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N F AVE
DOUGLAS AZ
85607-1919
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3285
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number229416
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: