Healthcare Provider Details

I. General information

NPI: 1104171685
Provider Name (Legal Business Name): RIGOBERTO GUTIERREZ JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 VAN BUREN BLVD
RIVERSIDE CA
92503-2098
US

IV. Provider business mailing address

6200 VAN BUREN BLVD
RIVERSIDE CA
92503-2098
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-0255
  • Fax:
Mailing address:
  • Phone: 951-358-0255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: