Provider Demographics
NPI:1174357255
Name:GUEVARA, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GUEVARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 REYNOLDS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5562
Mailing Address - Country:US
Mailing Address - Phone:657-900-4536
Mailing Address - Fax:
Practice Address - Street 1:1400 REYNOLDS AVE STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5562
Practice Address - Country:US
Practice Address - Phone:657-900-4536
Practice Address - Fax:657-208-9732
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65055363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant