MEDICARE: PALOMA PICON MACIAS B.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WLC505692	OTHER	LA	STATE DEPARTMENT OF EDUCATION

General Provider Information

NPI Number	:	1467104323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PALOMA PICON MACIAS B.A

Provider Business Mailing Address
First Line	:	2714 STOUT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-3056
Country	:	US
Telephone Number	:	504-235-1058
Fax Number	:

Provider Business Practice Location Address
First Line	:	5890 BEELER CT
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80238-2376
Country	:	US
Telephone Number	:	504-235-1058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	01/22/2022

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Directions to “ PALOMA PICON MACIAS B.A” Practice Location

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