Healthcare Provider Details

I. General information

NPI: 1275695538
Provider Name (Legal Business Name): GASTON ALBA GUTIERREZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 MONTANO RD NW
ALBUQUERQUE NM
87120-5743
US

IV. Provider business mailing address

85 WEST HIGHWAY 22
SANTO DOMINGO NM
87052
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-3892
  • Fax:
Mailing address:
  • Phone: 505-464-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number01771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: