Provider Demographics
NPI:1578739173
Name:SHIA, SUE YI (OTR)
Entity Type:Individual
Prefix:MISS
First Name:SUE
Middle Name:YI
Last Name:SHIA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 WILLIAM MOSS BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-5666
Mailing Address - Country:US
Mailing Address - Phone:209-221-5970
Mailing Address - Fax:
Practice Address - Street 1:1422 WILLIAM MOSS BLVD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-5666
Practice Address - Country:US
Practice Address - Phone:209-221-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT6716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist