Provider Demographics
NPI:1619001211
Name:GUZMAN, MYRA ATHENA (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:ATHENA
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MYRA
Other - Middle Name:ATHENA
Other - Last Name:WITHERSPOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1274
Mailing Address - Country:US
Mailing Address - Phone:919-620-4467
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:10211 ALM ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8221
Practice Address - Country:US
Practice Address - Phone:919-620-4467
Practice Address - Fax:919-620-4921
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032271E207Q00000X
SC23426207Q00000X
GA045152207Q00000X
NC9800165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCEO2221Medicare UPIN