Provider Demographics
NPI:1881746196
Name:GUILLEN, ROBERTO CARLOS (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:CARLOS
Last Name:GUILLEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:509-865-0757
Practice Address - Street 1:3896 BEVERLY AVE NE STE 40
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1374
Practice Address - Country:US
Practice Address - Phone:503-588-0076
Practice Address - Fax:503-588-7578
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15859363AM0700X
ORPA207674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical