Basic Information
| Provider Information | |||||||||
| NPI: | 1922482652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADRID | ||||||||
| FirstName: | ROXANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASCARENAS | ||||||||
| OtherFirstName: | ROXANN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 27258 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871257258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057648231 | ||||||||
| FaxNumber: | 5052481351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057648231 | ||||||||
| FaxNumber: | 5052481351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 261QM0801X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.