Basic Information
| Provider Information | |||||||||
| NPI: | 1588622476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUEVARA | ||||||||
| FirstName: | ANDRE | ||||||||
| MiddleName: | RIVERO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6240 SW 21ST ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331552057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059869166 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Practice Location | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9100748 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003889000 | 05 | FL | MEDICAID |