Provider Demographics
NPI:1295507200
Name:BETANCUR, MARIA ISABEL
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ISABEL
Last Name:BETANCUR
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 1:9870 COLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4243
Mailing Address - Country:US
Mailing Address - Phone:770-895-6996
Mailing Address - Fax:
Practice Address - Street 1:3790 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4801
Practice Address - Country:US
Practice Address - Phone:470-545-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN290472363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care