Provider Demographics
NPI:1124046305
Name:GUADARRAMA, CHARISE YVONNE (PA)
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:YVONNE
Last Name:GUADARRAMA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MALTS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2509
Mailing Address - Country:US
Mailing Address - Phone:631-888-3771
Mailing Address - Fax:
Practice Address - Street 1:93-19 ROOSEVELT AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-803-8463
Practice Address - Fax:718-803-8465
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850219Medicaid
P00392217Medicare PIN
Q75132Medicare UPIN
NY8221L35971Medicare PIN