Provider Demographics
NPI:1821799891
Name:FREDERICA NINA SU
Entity Type:Organization
Organization Name:FREDERICA NINA SU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-375-1611
Mailing Address - Street 1:1000 NEWBURY RD STE 115
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6436
Mailing Address - Country:US
Mailing Address - Phone:805-375-1611
Mailing Address - Fax:
Practice Address - Street 1:1000 NEWBURY RD STE 115
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-6436
Practice Address - Country:US
Practice Address - Phone:805-375-1611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty