Healthcare Provider Details

I. General information

NPI: 1699413500
Provider Name (Legal Business Name): ANTHONY GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9532 E 16 FRONTAGE RD
ONALASKA WI
54650-6739
US

IV. Provider business mailing address

9532 E 16 FRONTAGE RD
ONALASKA WI
54650-6739
US

V. Phone/Fax

Practice location:
  • Phone: 608-783-0506
  • Fax:
Mailing address:
  • Phone: 608-783-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number149882-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: