Healthcare Provider Details

I. General information

NPI: 1902537632
Provider Name (Legal Business Name): LUIS GINO PRADA GUZMAN DNP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 US HIGHWAY 1 N
ISELIN NJ
08830-2652
US

IV. Provider business mailing address

740 US HIGHWAY 1 N
ISELIN NJ
08830-2652
US

V. Phone/Fax

Practice location:
  • Phone: 732-874-5507
  • Fax: 732-874-5508
Mailing address:
  • Phone: 732-874-5507
  • Fax: 732-874-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01377500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: