Healthcare Provider Details

I. General information

NPI: 1902260292
Provider Name (Legal Business Name): NICHOLAS GUTIERREZ ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

909 SANTA ROSA BLVD UNIT 519
FORT WALTON BEACH FL
32548-5900
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8341
  • Fax:
Mailing address:
  • Phone: 850-896-7413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 4367
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: