MEDICARE: PAUL MARTIN T GUERRERO III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	819413	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1790384246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL MARTIN T GUERRERO III

Provider Business Mailing Address
First Line	:	5505 DUNSHEE VISTA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2026
Country	:	US
Telephone Number	:	702-768-3594
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 DUNSHEE VISTA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2026
Country	:	US
Telephone Number	:	702-768-3594
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2020
Last Update Date	:	10/25/2020

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