Healthcare Provider Details

I. General information

NPI: 1548943202
Provider Name (Legal Business Name): MR. MARIO MIGLIORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 4TH ST NW
ALBUQUERQUE NM
87107-2510
US

IV. Provider business mailing address

1011 MATADOR DR SE
ALBUQUERQUE NM
87123-4222
US

V. Phone/Fax

Practice location:
  • Phone: 505-975-1304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: