Provider Demographics
NPI:1669681045
Name:EDWARDS-GUISHARD, GLENNIS NAOMI (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:GLENNIS
Middle Name:NAOMI
Last Name:EDWARDS-GUISHARD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MRS
Other - First Name:GLENNIS
Other - Middle Name:NAOMI
Other - Last Name:EDWARDS-GUISHARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:964 E 179TH ST
Mailing Address - Street 2:PRIVATE BOX 7
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-2270
Mailing Address - Country:US
Mailing Address - Phone:347-223-7730
Mailing Address - Fax:
Practice Address - Street 1:16TH STREET 1ST AVENUE
Practice Address - Street 2:9 BERNSTEIN
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-420-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006478363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical