Healthcare Provider Details

I. General information

NPI: 1801482930
Provider Name (Legal Business Name): TEDI GUMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2020
Last Update Date: 12/13/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7949 MYRTLE AVE
GLENDALE NY
11385-7451
US

IV. Provider business mailing address

7949 MYRTLE AVE
GLENDALE NY
11385-7451
US

V. Phone/Fax

Practice location:
  • Phone: 718-682-7448
  • Fax:
Mailing address:
  • Phone: 718-682-7448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025994
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: