Basic Information
| Provider Information | |||||||||
| NPI: | 1275921579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRY | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2255 E MOSSY OAKS RD | ||||||||
| Address2: | STE 680 | ||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773891812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815370300 | ||||||||
| FaxNumber: | 8323812062 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 E MOSSY OAKS RD | ||||||||
| Address2: | STE 680 | ||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773891812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815370300 | ||||||||
| FaxNumber: | 8323812062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2015 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA09559 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | PA09559 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | PA09559 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | PA09559 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PA09559 | 01 | TX | MEDICAL LICENSE | OTHER |