Basic Information
| Provider Information | |||||||||
| NPI: | 1629571062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | VILLANUEVA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4228 SW 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330273174 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8900 N KENDALL DR | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331762118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865962000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2018 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | PA9111144 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 363A00000X | 9111144 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2080P0204X | 9111144 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.