Healthcare Provider Details

I. General information

NPI: 1043846785
Provider Name (Legal Business Name): JOAQUIN A PUENTE CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10275 LITTLE PATUXENT PKWY STE 300
COLUMBIA MD
21044-3445
US

IV. Provider business mailing address

10275 LITTLE PATUXENT PKWY STE 300
COLUMBIA MD
21044-3445
US

V. Phone/Fax

Practice location:
  • Phone: 734-545-4420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number4024
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number10070061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: