1174972822 NPI number — MS. HEATHER NICOLE GUTIERREZ PA-S

Table of content: MS. HEATHER NICOLE GUTIERREZ PA-S (NPI 1174972822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174972822 NPI number — MS. HEATHER NICOLE GUTIERREZ PA-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
HEATHER
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174972822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98206-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-293-4343
Provider Business Mailing Address Fax Number:
360-588-1587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221-3473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-293-4343
Provider Business Practice Location Address Fax Number:
360-588-1587
Provider Enumeration Date:
06/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA60803282 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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