Basic Information
| Provider Information | |||||||||
| NPI: | 1508237587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUNGO | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | GUEVARRA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 BLUEBELL BROOK ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143903386 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2015 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95003197 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN002363 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1508237587 | 05 | NV | MEDICAID |