Provider Demographics
NPI:1114492196
Name:GUZMAN AGUILAR, KEVIN JORGE (SA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JORGE
Last Name:GUZMAN AGUILAR
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 54TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1928
Mailing Address - Country:US
Mailing Address - Phone:201-355-7656
Mailing Address - Fax:
Practice Address - Street 1:3240 54TH ST FL 2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1928
Practice Address - Country:US
Practice Address - Phone:201-355-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-412246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant