Healthcare Provider Details

I. General information

NPI: 1073221313
Provider Name (Legal Business Name): MARIA HULTQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA MARION

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 MCMAHON BLVD NW STE 109
ALBUQUERQUE NM
87114-5412
US

IV. Provider business mailing address

4609 TAYLOR RIDGE RD NW
ALBUQUERQUE NM
87120-5716
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-5037
  • Fax:
Mailing address:
  • Phone: 505-379-5037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: