Healthcare Provider Details

I. General information

NPI: 1679394845
Provider Name (Legal Business Name): MARIA CORONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CAJUN CT
ROSWELL NM
88201-3408
US

IV. Provider business mailing address

3 CAJUN CT
ROSWELL NM
88201-3408
US

V. Phone/Fax

Practice location:
  • Phone: 575-317-4504
  • Fax:
Mailing address:
  • Phone: 575-317-4504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number215422
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: