Provider Demographics
NPI:1891451084
Name:PALOMARES, MIA JADE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:JADE
Last Name:PALOMARES
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S SCHWARTZ AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-1314
Mailing Address - Country:US
Mailing Address - Phone:915-781-5668
Mailing Address - Fax:
Practice Address - Street 1:5700 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-1773
Practice Address - Country:US
Practice Address - Phone:505-599-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM8882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program