=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336809151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINO CARLO JOSEPH GUTIERREZ CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2021
-----------------------------------------------------
Last Update Date | 02/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 KINGSLEY AVE
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-639-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 FAIRWAY PARK BLVD UNIT 1012
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | APRN11017003
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------