Provider Demographics
NPI:1881345767
Name:MARQUIS, CRYSTAL ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:MARQUIS
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 1:3902 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-4632
Mailing Address - Country:US
Mailing Address - Phone:505-402-6182
Mailing Address - Fax:
Practice Address - Street 1:2300 E 30TH ST STE C2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8991
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2021-0119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine