Provider Demographics
NPI:1851717714
Name:SERROS, MARK 'MARKOS' (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:'MARKOS'
Last Name:SERROS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 PAN AMERICAN FWY NE APT 108
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4708
Mailing Address - Country:US
Mailing Address - Phone:505-974-3989
Mailing Address - Fax:
Practice Address - Street 1:4300 PAN AMERICAN FREEWAY #108
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-974-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7844173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7844OtherSELF