Healthcare Provider Details

I. General information

NPI: 1336809151
Provider Name (Legal Business Name): LINO CARLO JOSEPH GUTIERREZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

100 FAIRWAY PARK BLVD UNIT 1012
PONTE VEDRA BEACH FL
32082-2623
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11017003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: