=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669681045
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLENNIS NAOMI EDWARDS-GUISHARD PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16TH STREET 1ST AVENUE 9 BERNSTEIN
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-420-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 964 E 179TH ST PRIVATE BOX 7
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10460-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-223-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 006478
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------