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General NPI Number Information
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NPI Number | 1962127878
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Entity Type | Organization
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Legal Business Name | MARIPOSA TRANSFORMATION WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 10/04/2022
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Last Update Date | 03/30/2023
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Provider Practice Location Address
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Address Line | 4550 EUBANK BLVD NE SUITE D205
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-2565
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Country | US
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Telephone | 505-234-6432
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Fax |
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Provider Business Mailing Address
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Address Line | 4550 EUBANK BLVD NE SUITE D205
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City | ALBUQUERQUE
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State | NM
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Zip | 87111
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Country | US
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Telephone | 505-234-6432
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Fax |
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Authorized Official
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Title or Position | PA-C / OWNER
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Name | MS. MICHELLE RENEE LUCERO
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Credential | PA-C
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Telephone | 505-234-6432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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