Provider Demographics
NPI:1407199052
Name:GUAJARDO, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GUAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S WOLFE ST
Mailing Address - Street 2:APT. 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1903
Mailing Address - Country:US
Mailing Address - Phone:845-401-5251
Mailing Address - Fax:
Practice Address - Street 1:MSC07 4040 1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-272-3053
Practice Address - Fax:505-925-0546
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program