Provider Demographics
NPI:1275630733
Name:MARION LUQUE,PLLC
Entity Type:Organization
Organization Name:MARION LUQUE,PLLC
Other - Org Name:WINDING CREEK MEDICAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARION
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-8887
Mailing Address - Street 1:502 E. TWO RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-559-3303
Mailing Address - Fax:
Practice Address - Street 1:1139 E. WINDING CREEK DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-938-8887
Practice Address - Fax:208-938-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805377200Medicaid
IDM8345OtherSTATE LICENSE
IDG79554Medicare UPIN
ID805377200Medicaid