Provider Demographics
NPI:1568506590
Name:HERBER, SUSAN ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:HERBER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GOLD AVE SW
Mailing Address - Street 2:#605
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3480
Mailing Address - Country:US
Mailing Address - Phone:505-205-0144
Mailing Address - Fax:
Practice Address - Street 1:300 PASEO DEL PUEBLO SUR
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-776-8421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0052363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40286525Medicaid