Provider Demographics
NPI:1346374238
Name:SUSAN R FERNANDEZ PC
Entity Type:Organization
Organization Name:SUSAN R FERNANDEZ PC
Other - Org Name:HORIZON RIDGE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:T
Authorized Official - Last Name:SAN JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-263-1908
Mailing Address - Street 1:2621 W HORIZON RIDGE PKWY #100
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052
Mailing Address - Country:US
Mailing Address - Phone:702-263-1908
Mailing Address - Fax:702-263-0195
Practice Address - Street 1:2621 W HORIZON RIDGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2895
Practice Address - Country:US
Practice Address - Phone:702-263-1908
Practice Address - Fax:702-263-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018477Medicaid
NV002018477Medicaid