Provider Demographics
NPI:1396515755
Name:GUEVARA, MATTHEW RICARDO
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICARDO
Last Name:GUEVARA
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 1:80 ROSELAWN RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930-3202
Mailing Address - Country:US
Mailing Address - Phone:845-499-8565
Mailing Address - Fax:
Practice Address - Street 1:80 ROSELAWN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-3202
Practice Address - Country:US
Practice Address - Phone:845-499-8565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363535163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse