Provider Demographics
NPI:1689262586
Name:SU, SELINA (PA-C)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:
Last Name:SU
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 1:3774 DONALD DR
Mailing Address - Street 2:
Mailing Address - City:GARNET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19060-1525
Mailing Address - Country:US
Mailing Address - Phone:484-350-1167
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:484-350-1167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062169363A00000X
PAOA005451363A00000X
MDC0007869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant