Healthcare Provider Details

I. General information

NPI: 1790903862
Provider Name (Legal Business Name): GERARD STEVEN GUZMAN RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4724 NESCONSET HWY
PORT JEFFERSON STATION NY
11776-2580
US

IV. Provider business mailing address

1345 RXR PLZ FL 13
UNIONDALE NY
11556-1301
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-5900
  • Fax: 631-828-1946
Mailing address:
  • Phone: 516-453-0435
  • Fax: 646-846-3283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004010
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: