Healthcare Provider Details

I. General information

NPI: 1275364564
Provider Name (Legal Business Name): GABRIEL GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 CAMINO ROJO
SANTA FE NM
87507-3421
US

IV. Provider business mailing address

6762 CAMINO ROJO
SANTA FE NM
87507-3421
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-5363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number24000210
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: