Basic Information
| Provider Information | |||||||||
| NPI: | 1508068933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGOSTO-MARQUEZ | ||||||||
| FirstName: | JANELLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026413212 | ||||||||
| FaxNumber: | 7024590320 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 N NELLIS BLVD | ||||||||
| Address2: | SMA/OB | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891105382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026413212 | ||||||||
| FaxNumber: | 7024590320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 13320 | NV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P00915402 | 01 | NV | RAILROAD | OTHER | BP2-0018490 | 01 | INSTITUTIONAL PERMIT | OTHER | CP678Z | 01 | NV | ORIGINAL MEDICARE # | OTHER | 1508068933 | 05 | NV | MEDICAID |