Healthcare Provider Details

I. General information

NPI: 1316073448
Provider Name (Legal Business Name): MARIJO NICOLE AGUILERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIJO NICOLE SOREM MD

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WABASHA ST S
SAINT PAUL MN
55107
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-293-8100
  • Fax: 651-293-8105
Mailing address:
  • Phone: 651-293-8100
  • Fax: 651-293-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number51556
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number51556
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: