Provider Demographics
NPI:1376108589
Name:GUILLEN, EDGAR CARDENAS (PT DPT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:CARDENAS
Last Name:GUILLEN
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 NE RIDDELL RD STE 170
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3060
Mailing Address - Country:US
Mailing Address - Phone:760-412-0091
Mailing Address - Fax:360-824-6720
Practice Address - Street 1:1550 NE RIDDELL RD STE 170
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3060
Practice Address - Country:US
Practice Address - Phone:360-474-3274
Practice Address - Fax:360-824-6720
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61103454225100000X
MO2019030009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist