Healthcare Provider Details

I. General information

NPI: 1639728124
Provider Name (Legal Business Name): MINERVA MARQUEZ MACIAS AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-5000
  • Fax:
Mailing address:
  • Phone: 310-423-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP95012243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: