MEDICARE: MR. DAVID GUTIERREZ PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110840444	VA

General Provider Information

NPI Number	:	1033110127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID GUTIERREZ PA-C

Provider Business Mailing Address
First Line	:	2620 JANSON DR
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-3808
Country	:	US
Telephone Number	:	757-488-3899
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 TAUSSIG BLVD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23511
Country	:	US
Telephone Number	:	747-314-6329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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