Basic Information
| Provider Information | |||||||||
| NPI: | 1083019012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAJARDO | ||||||||
| FirstName: | GUDALIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45640 SCHOENHERR RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | UTICA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483156033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862474300 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Practice Location | |||||||||
| Address1: | 2603 ELECTRIC AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109875252 | ||||||||
| FaxNumber: | 8109872120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704267837 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.