Basic Information
| Provider Information | |||||||||
| NPI: | 1619001211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUZMAN | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | ATHENA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WITHERSPOON | ||||||||
| OtherFirstName: | MYRA | ||||||||
| OtherMiddleName: | ATHENA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 751274 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204467 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Practice Location | |||||||||
| Address1: | 10211 ALM ST | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276178221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204467 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD032271E | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 23426 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 045152 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9800165 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.