Provider Demographics
NPI:1265448294
Name:DE GUZMAN, GLENN MICHAEL (PA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:MICHAEL
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19416 CHEYENNE WELLS CIR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4371
Mailing Address - Country:US
Mailing Address - Phone:562-868-0733
Mailing Address - Fax:
Practice Address - Street 1:13330 BLOOMFIELD AVE STE 111
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3264
Practice Address - Country:US
Practice Address - Phone:562-868-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA18213Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER