Provider Demographics
NPI:1851896559
Name:VERGARA, GUIDO S (FNP)
Entity Type:Individual
Prefix:
First Name:GUIDO
Middle Name:S
Last Name:VERGARA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 WATSEKA AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3925
Mailing Address - Country:US
Mailing Address - Phone:310-986-0191
Mailing Address - Fax:
Practice Address - Street 1:7211 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2256
Practice Address - Country:US
Practice Address - Phone:818-988-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine