Healthcare Provider Details

I. General information

NPI: 1730654278
Provider Name (Legal Business Name): DEHCONTEE GUAR CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 WALNUT ST
PHILADELPHIA PA
19139-3706
US

IV. Provider business mailing address

15 EAGLE WAY
AVONDALE PA
19311-9723
US

V. Phone/Fax

Practice location:
  • Phone: 215-476-6264
  • Fax: 215-689-0893
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG0012151
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP019392
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: