Provider Demographics
NPI:1679020481
Name:GUZMAN, LISAMAR ROLON (MT)
Entity Type:Individual
Prefix:
First Name:LISAMAR
Middle Name:ROLON
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:A10 CALLE 1
Mailing Address - Street 2:VILLA MATILDE
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-2304
Mailing Address - Country:US
Mailing Address - Phone:787-870-2200
Mailing Address - Fax:
Practice Address - Street 1:A10 CALLE 1
Practice Address - Street 2:VILLA MATILDE
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-870-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR40D2113067Medicaid