Provider Demographics
NPI:1033706643
Name:PISANO, SUSAN M (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:PISANO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PASILLO CHICO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9581
Mailing Address - Country:US
Mailing Address - Phone:505-660-8589
Mailing Address - Fax:
Practice Address - Street 1:1651 GALISTEO ST STE 12
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2113
Practice Address - Country:US
Practice Address - Phone:505-660-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDC1234111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor