Healthcare Provider Details

I. General information

NPI: 1225765480
Provider Name (Legal Business Name): MARICAR TACBAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 HARPER DR NE
ALBUQUERQUE NM
87109-3573
US

IV. Provider business mailing address

5700 HARPER DR NE
ALBUQUERQUE NM
87109-3573
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-7813
  • Fax:
Mailing address:
  • Phone: 505-843-7813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0074
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: