Provider Demographics
NPI:1700644580
Name:BALDERAS VASQUEZ, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BALDERAS VASQUEZ
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:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0305
Mailing Address - Country:US
Mailing Address - Phone:541-248-0092
Mailing Address - Fax:
Practice Address - Street 1:1305 HILL ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6711
Practice Address - Country:US
Practice Address - Phone:541-248-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker