Healthcare Provider Details

I. General information

NPI: 1710348024
Provider Name (Legal Business Name): EDISSON GUAMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12373 COLONY PRESERVE DR
BOYNTON BEACH FL
33436-5807
US

IV. Provider business mailing address

12373 COLONY PRESERVE DR
BOYNTON BEACH FL
33436-5807
US

V. Phone/Fax

Practice location:
  • Phone: 561-617-0686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9110396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: