Healthcare Provider Details

I. General information

NPI: 1003800640
Provider Name (Legal Business Name): STEVEN M GUALDONI PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE STE 332
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

1414 W FAIR AVE STE 332
MARQUETTE MI
49855-2675
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3922
  • Fax: 906-225-4527
Mailing address:
  • Phone: 906-225-3922
  • Fax: 906-225-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001259
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: