Healthcare Provider Details

I. General information

NPI: 1467373787
Provider Name (Legal Business Name): MARSHA MARY MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 JOURNAL CENTER BLVD NE
ALBUQUERQUE NM
87109-5900
US

IV. Provider business mailing address

4365 GOLDEN EAGLE LOOP NE
RIO RANCHO NM
87144-7692
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-3212
  • Fax:
Mailing address:
  • Phone: 505-217-4676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number90523
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: