Provider Demographics
NPI:1952078883
Name:FUENTES, MARIO ALBERTO (RRT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ALBERTO
Last Name:FUENTES
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8186 W COLCORD CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043
Mailing Address - Country:US
Mailing Address - Phone:480-236-0677
Mailing Address - Fax:
Practice Address - Street 1:N7, CORNER OF ROUTES N12
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:480-236-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ022825227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered