MEDICARE: MR. WILSON GUTIERREZ

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	RN176420	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730589342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILSON GUTIERREZ

Provider Business Mailing Address
First Line	:	PO BOX 4000
Second Line	:
City	:	POLACCA
State	:	AZ
Zip	:	86042-4000
Country	:	US
Telephone Number	:	928-737-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 N RECKER RD UNIT 1047
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-5548
Country	:	US
Telephone Number	:	623-302-8137
Fax Number	:

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

Provider Enumeration Date	:	09/02/2014
Last Update Date	:	09/02/2014

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