Healthcare Provider Details

I. General information

NPI: 1366101073
Provider Name (Legal Business Name): MAYRA GUMA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11217 65TH AVE
SAN JUAN PR
00987
US

IV. Provider business mailing address

1785 CALLE J FERRER Y FERRER APT 310
SAN JUAN PR
00921-4185
US

V. Phone/Fax

Practice location:
  • Phone: 787-276-7191
  • Fax:
Mailing address:
  • Phone: 787-307-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number27219
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: