Provider Demographics
NPI:1720710981
Name:GUEVARRA, JUSTINE CARLO GARCIA
Entity Type:Individual
Prefix:
First Name:JUSTINE CARLO
Middle Name:GARCIA
Last Name:GUEVARRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PENN AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-2012
Mailing Address - Country:US
Mailing Address - Phone:570-677-5525
Mailing Address - Fax:
Practice Address - Street 1:501 S WASHINGTON AVE STE 1000
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-3814
Practice Address - Country:US
Practice Address - Phone:570-343-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT227297390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program