Provider Demographics
NPI:1629116306
Name:BLAIR-BUCKLEY, SUSAN GAY (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAY
Last Name:BLAIR-BUCKLEY
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 1:4340 SAN MATEO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1234
Mailing Address - Country:US
Mailing Address - Phone:505-252-0599
Mailing Address - Fax:
Practice Address - Street 1:4340 SAN MATEO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1234
Practice Address - Country:US
Practice Address - Phone:505-252-0599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006-0025363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP011039980OtherRR MEDICARE
NM12753076Medicaid
Q77289Medicare UPIN
NMP011039980OtherRR MEDICARE