Provider Demographics
NPI:1811745060
Name:GUZMAN, NICOLE CARMEN (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CARMEN
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-3133
Mailing Address - Country:US
Mailing Address - Phone:347-446-0637
Mailing Address - Fax:
Practice Address - Street 1:904 BAYONNE CROSSING WAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-5307
Practice Address - Country:US
Practice Address - Phone:551-497-5675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
NJ25MP00879300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant