Healthcare Provider Details

I. General information

NPI: 1568319564
Provider Name (Legal Business Name): MARTHA MARIE QUINTANA-SERNA PED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 N POPE ST
SILVER CITY NM
88061
US

IV. Provider business mailing address

PO BOX 305 313 CUPRITE ST
TYRONE NM
88065-0305
US

V. Phone/Fax

Practice location:
  • Phone: 575-597-2415
  • Fax: 575-313-8236
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberN0047800
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: