Provider Demographics
NPI:1295003457
Name:GUEVARA, ERIC (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GUEVARA
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 1:1310 W STEWART DR STE 510
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3856
Mailing Address - Country:US
Mailing Address - Phone:714-538-8549
Mailing Address - Fax:714-538-1547
Practice Address - Street 1:1310 W STEWART DR STE 510
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3856
Practice Address - Country:US
Practice Address - Phone:714-538-8549
Practice Address - Fax:714-538-1547
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21798OtherLICENSE NO