Provider Demographics
NPI:1417780834
Name:MARCO, AGNES BALLESTEROS
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:BALLESTEROS
Last Name:MARCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 BAKER ST # 14
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93305-4341
Mailing Address - Country:US
Mailing Address - Phone:661-328-4283
Mailing Address - Fax:661-843-8619
Practice Address - Street 1:1015 BAKER ST # 14
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4341
Practice Address - Country:US
Practice Address - Phone:661-328-4283
Practice Address - Fax:661-843-8619
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily