Provider Demographics
NPI:1730640848
Name:GUTIERREZ, JOSUE RAFAEL
Entity type:Individual
Prefix:
First Name:JOSUE
Middle Name:RAFAEL
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6458 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-5120
Mailing Address - Country:US
Mailing Address - Phone:916-547-6348
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-689-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program