Healthcare Provider Details

I. General information

NPI: 1396210506
Provider Name (Legal Business Name): MARIPOSA FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3868
US

IV. Provider business mailing address

5910 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3868
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-3321
  • Fax: 505-212-0152
Mailing address:
  • Phone: 505-859-4191
  • Fax: 505-308-3192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TANI SCHARE
Title or Position: OWNER
Credential: FNP-C
Phone: 505-859-4191