Provider Demographics
NPI:1902537632
Name:GUZMAN, LUIS GINO PRADA (APN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:LUIS GINO
Middle Name:PRADA
Last Name:GUZMAN
Suffix:
Gender:M
Credentials:APN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2496
Mailing Address - Country:US
Mailing Address - Phone:929-428-5444
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020245363LF0000X
NJ26NJ01377500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily