Healthcare Provider Details

I. General information

NPI: 1700242112
Provider Name (Legal Business Name): GUSTAVO GUTIERREZ CPNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S COUNTY LINE DR
CHAPARRAL NM
88081
US

IV. Provider business mailing address

385 CALLE DE ALEGRA BLDG. A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-0820
  • Fax: 575-824-1021
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP-02890
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP129867
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP129867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: