Healthcare Provider Details

I. General information

NPI: 1902658792
Provider Name (Legal Business Name): PAUL JUAN MARQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 05/23/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 N BLACKSTONE AVE
FRESNO CA
93701-1913
US

IV. Provider business mailing address

258 N BLACKSTONE AVE
FRESNO CA
93701-1913
US

V. Phone/Fax

Practice location:
  • Phone: 559-274-0299
  • Fax:
Mailing address:
  • Phone: 559-274-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: