Provider Demographics
NPI:1396443222
Name:BARAJAS, MARISOL
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:BARAJAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 YELLOWBIRD LN
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-7703
Mailing Address - Country:US
Mailing Address - Phone:601-347-5111
Mailing Address - Fax:
Practice Address - Street 1:1850 GAUSE BLVD E STE 301
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5434
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily