Healthcare Provider Details

I. General information

NPI: 1568852648
Provider Name (Legal Business Name): LAUREN MACQUARRIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 UNIVERSITY BLVD NE
ALBUQUERQUE NM
87102-1708
US

IV. Provider business mailing address

4668 GREENE ST NW
ALBUQUERQUE NM
87114-4248
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0789
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: