Healthcare Provider Details

I. General information

NPI: 1992727572
Provider Name (Legal Business Name): MARISA AIKEN SANCHEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE 5A-111
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE 5A-111
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-2803
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2013-0064
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: