Provider Demographics
NPI:1083811665
Name:SURYA, HERALD
Entity Type:Individual
Prefix:DR
First Name:HERALD
Middle Name:
Last Name:SURYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 E FORT LOWELL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2378
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:1075 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719
Practice Address - Country:US
Practice Address - Phone:520-202-1960
Practice Address - Fax:520-622-5358
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11012363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ363298Medicaid