Healthcare Provider Details

I. General information

NPI: 1407120413
Provider Name (Legal Business Name): MARAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 MONTGOMERY PKWY NE STE 150
ALBUQUERQUE NM
87111-3876
US

IV. Provider business mailing address

10401 MONTGOMERY PKWY NE STE 150
ALBUQUERQUE NM
87111-3876
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-1040
  • Fax: 505-407-8150
Mailing address:
  • Phone: 505-234-1040
  • Fax: 505-407-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01745
License Number StateNM

VIII. Authorized Official

Name: ANDREI MARCHENKO
Title or Position: OWNER
Credential: CNP
Phone: 505-234-1040