Provider Demographics
NPI:1831348986
Name:ENRIQUEZ, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ENRIQUEZ
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 1:226 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-1422
Mailing Address - Country:US
Mailing Address - Phone:520-620-1055
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:226 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1422
Practice Address - Country:US
Practice Address - Phone:520-620-1055
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-13
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9525171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9525Medicaid