MEDICARE: MR. GENE C HUTSELL NP

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	163W00000X	Registered Nurse	RN114639	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP30004998	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP30004998	OTHER	WA	WA STATE
2	646995	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1720030406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GENE C HUTSELL NP

Provider Business Mailing Address
First Line	:	PO BOX 813
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-0813
Country	:	US
Telephone Number	:	928-669-6669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 PUEBLO DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-8918
Country	:	US
Telephone Number	:	928-669-6669
Fax Number	:

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	08/11/2020

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