Healthcare Provider Details

I. General information

NPI: 1790394468
Provider Name (Legal Business Name): LUIS GABRIEL MARQUEZ FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

6308 TAUTON PL NW
ALBUQUERQUE NM
87120-6231
US

V. Phone/Fax

Practice location:
  • Phone: 505-269-6753
  • Fax:
Mailing address:
  • Phone: 505-485-9471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number60689
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: