Provider Demographics
NPI:1477542371
Name:SIA SU, WALTER LO (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LO
Last Name:SIA SU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRA CARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRA CARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN37684207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
526021OtherARAZ GROUP AMERICAS PPO
114449OtherUCARE
MN242513100Medicaid
HP21690OtherHEALTH PARTNERS
0407506OtherMEDICA HEALTH PLANS
242513100OtherMEDICAL ASSISTANCE
1013234OtherPREFERRED ONE
379K3S1OtherBLUE CROSS BLUE SHIELD
F93083Medicare UPIN
MN242513100Medicaid
526021OtherARAZ GROUP AMERICAS PPO