Provider Demographics
NPI:1700457066
Name:MARROQUIN, BRANDON IVAN
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:IVAN
Last Name:MARROQUIN
Suffix:
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 1:33020 TANK DESTROYER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-4901
Mailing Address - Country:US
Mailing Address - Phone:505-913-0764
Mailing Address - Fax:
Practice Address - Street 1:33003 BATTALION AVE
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-618-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2644-4876-2654146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic