Provider Demographics
NPI:1922674290
Name:SU, AMY
Entity Type:Individual
Prefix:
First Name:AMY
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 1:25405 HANCOCK AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25405 HANCOCK AVE STE 216
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5978
Practice Address - Country:US
Practice Address - Phone:951-698-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-11-18
Deactivation Date:2021-09-20
Deactivation Code:
Reactivation Date:2021-11-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant