Provider Demographics
NPI:1609354398
Name:ESCOBAR, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:ESCOBAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10804 DREAM WEAVER DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5060
Mailing Address - Country:US
Mailing Address - Phone:505-897-5065
Mailing Address - Fax:
Practice Address - Street 1:3613 STATE HWY 528 NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-8918
Practice Address - Country:US
Practice Address - Phone:505-897-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03594363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner