Provider Demographics
NPI:1467429654
Name:PATRIQUIN, LARA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:MARIE
Last Name:PATRIQUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 THE 25 WAY NE
Mailing Address - Street 2:#150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-332-6900
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:#150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-6900
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD200401202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ880676Medicaid
NM45152381Medicaid
H41986Medicare UPIN
AZ880676Medicaid
NM45152381Medicaid