Provider Demographics
NPI:1841524006
Name:BENSULOCK, MARIE L (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:BENSULOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 BARSTOW ST NE APT 13104
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2876
Mailing Address - Country:US
Mailing Address - Phone:505-508-0701
Mailing Address - Fax:
Practice Address - Street 1:803 TIJERAS AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3096
Practice Address - Country:US
Practice Address - Phone:505-243-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2008-0001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical