Provider Demographics
NPI:1679180848
Name:SU, JINXIANG
Entity Type:Individual
Prefix:
First Name:JINXIANG
Middle Name:
Last Name:SU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 ELEMENT WAY APT 415
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4678
Mailing Address - Country:US
Mailing Address - Phone:615-839-7541
Mailing Address - Fax:
Practice Address - Street 1:2301 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5230
Practice Address - Country:US
Practice Address - Phone:920-490-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20501-40183500000X
WV20501-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist