Provider Demographics
NPI:1639524333
Name:GUILLEN, JOSE ENRIQUE JR (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ENRIQUE
Last Name:GUILLEN
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7921 BERMEJO RD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-6144
Mailing Address - Country:US
Mailing Address - Phone:503-442-7307
Mailing Address - Fax:
Practice Address - Street 1:1715 CHILDERLEE LN NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2434
Practice Address - Country:US
Practice Address - Phone:503-442-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1132245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant