Healthcare Provider Details

I. General information

NPI: 1275630733
Provider Name (Legal Business Name): MARION LUQUE,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 E. WINDING CREEK DR
EAGLE ID
83616
US

IV. Provider business mailing address

502 E. TWO RIVERS DR
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-8887
  • Fax: 208-938-8897
Mailing address:
  • Phone: 208-559-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM8345
License Number StateID

VIII. Authorized Official

Name: DR. MARION LYNN LUQUE
Title or Position: OWNER
Credential: M.D.
Phone: 208-938-8887