Provider Demographics
NPI:1669112355
Name:MARQUEZ, JOHN JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MARQUEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3213
Mailing Address - Country:US
Mailing Address - Phone:631-383-8373
Mailing Address - Fax:
Practice Address - Street 1:2646 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3213
Practice Address - Country:US
Practice Address - Phone:631-383-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287159164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497374060Medicaid