MEDICARE: TANYA V MARIN, PC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1720469679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TANYA V MARIN, PC

Provider Business Mailing Address
First Line	:	1245 COUNTRY CLUB RD
Second Line	:	SUITE 200
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:	575-332-4635

Provider Business Practice Location Address
First Line	:	1245 COUNTRY CLUB RD
Second Line	:	SUITE 200
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:	575-332-4635

Authorized Official
Title or Position	:	PEDIATRIC NURSE PRACTITIONER/ OWNER
Name	:	DR. TANYA VERONICA MARIN
Credential	:	DNP, APRN, CPNP-PC
Telephone Number	:	575-332-4633

Provider Enumeration Date	:	06/17/2015
Last Update Date	:	06/17/2015

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