Basic Information
| Provider Information | |||||||||
| NPI: | 1790903862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUZMAN | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ FL 13 | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
| FaxNumber: | 6468463283 | ||||||||
| Practice Location | |||||||||
| Address1: | 4724 NESCONSET HWY | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117762580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314745900 | ||||||||
| FaxNumber: | 6318281946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 004010 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 004010 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.