Provider Demographics
NPI:1306626759
Name:DE GUZMAN, JOHN JOSEPH (APRN)
Entity type:Individual
Prefix:
First Name:JOHN JOSEPH
Middle Name:
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W CHARLESTON BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1998
Mailing Address - Country:US
Mailing Address - Phone:702-476-9999
Mailing Address - Fax:
Practice Address - Street 1:1610 E LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7145
Practice Address - Country:US
Practice Address - Phone:702-476-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN811917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250027915Medicaid