Provider Demographics
NPI:1588107072
Name:GUERRERO, MARIO A (AGNP-C)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:A
Last Name:GUERRERO
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3261
Mailing Address - Country:US
Mailing Address - Phone:718-497-1919
Mailing Address - Fax:718-497-2152
Practice Address - Street 1:6655 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3261
Practice Address - Country:US
Practice Address - Phone:718-497-1919
Practice Address - Fax:718-497-2152
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3078871363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health