Provider Demographics
NPI:1467449488
Name:GUADALUPE, DAVID (AA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GUADALUPE
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-3076
Practice Address - Fax:864-455-4135
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3514367H00000X
FLAA83367H00000X
SC80367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid
GA100000942FMedicaid
GA100000942AMedicaid
GA100000942EMedicaid
GAP24443Medicare UPIN
GA97BBGGTMedicare PIN