Provider Demographics
NPI:1649825001
Name:CERECERES, MARLENE
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:CERECERES
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 1:3910 TANNER DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-6143
Mailing Address - Country:US
Mailing Address - Phone:432-270-2373
Mailing Address - Fax:
Practice Address - Street 1:1211 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6158
Practice Address - Country:US
Practice Address - Phone:432-262-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA13915363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program