Healthcare Provider Details

I. General information

NPI: 1790373447
Provider Name (Legal Business Name): ANTONIO ALEXANDRO BENJAMIN MARQUEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2105
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4107
  • Fax: 505-272-8098
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0095
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: