Provider Demographics
NPI:1033674924
Name:SUGER, PHILIP THOMAS (PHD, LAC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:THOMAS
Last Name:SUGER
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 LAKEVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5737
Mailing Address - Country:US
Mailing Address - Phone:415-515-8449
Mailing Address - Fax:
Practice Address - Street 1:17700 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-4018
Practice Address - Country:US
Practice Address - Phone:415-515-8449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01890171100000X
CAAC19371171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty