Provider Demographics
NPI:1588622476
Name:GUEVARA, ANDRE RIVERO (PA)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:RIVERO
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 1:6240 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-2057
Mailing Address - Country:US
Mailing Address - Phone:305-986-9166
Mailing Address - Fax:305-248-6558
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4934
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:305-248-6558
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100748363A00000X
FL9100748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003889000Medicaid
FL373831100Medicaid
FL003889000Medicaid
FLU0022YMedicare ID - Type Unspecified
FLU0022WMedicare PIN
FL003889000Medicaid
FL292131600Medicaid