Provider Demographics
NPI:1508257676
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:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-263-1908
Mailing Address - Street 1:2621 W. HORIZON RIDGE PWKY
Mailing Address - Street 2:SUITE 100
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 1:6843 W TROPICANA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4922
Practice Address - Country:US
Practice Address - Phone:702-818-3303
Practice Address - Fax:702-263-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9740208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003102477Medicaid