Provider Demographics
NPI:1497886634
Name:DE GUZMAN, IRENEO TUMALI (CRNA)
Entity Type:Individual
Prefix:MR
First Name:IRENEO
Middle Name:TUMALI
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:RENE
Other - Middle Name:TUMALI
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:619 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-3145
Mailing Address - Country:US
Mailing Address - Phone:406-366-0592
Mailing Address - Fax:
Practice Address - Street 1:408 WENDELL AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2261
Practice Address - Country:US
Practice Address - Phone:406-538-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX054510367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered