Provider Demographics
NPI:1184379786
Name:MARQUEZ, SUSANA PERALTA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:PERALTA
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2104
Mailing Address - Country:US
Mailing Address - Phone:610-210-5763
Mailing Address - Fax:
Practice Address - Street 1:8080 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2104
Practice Address - Country:US
Practice Address - Phone:619-589-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty