Provider Demographics
NPI:1104653369
Name:RUIZ DE MARTINEZ, FABIOLA (NP)
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:RUIZ DE MARTINEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12980 FREDERICK ST STE I
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5263
Mailing Address - Country:US
Mailing Address - Phone:951-243-3868
Mailing Address - Fax:
Practice Address - Street 1:12980 FREDERICK ST STE I
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5263
Practice Address - Country:US
Practice Address - Phone:951-243-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95031617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty