Healthcare Provider Details

I. General information

NPI: 1073351466
Provider Name (Legal Business Name): MARIAM ISSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 RICK FRANCIS ST # 24002
EL PASO TX
79905-2817
US

IV. Provider business mailing address

222 RICK FRANCIS ST # 24002
EL PASO TX
79905-2817
US

V. Phone/Fax

Practice location:
  • Phone: 915-215-6700
  • Fax:
Mailing address:
  • Phone: 915-215-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number40368
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: