Provider Demographics
NPI:1336259126
Name:TISO, SUSAN MARIE (NP)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:TISO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:TISO MCNANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1550 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3653
Mailing Address - Country:US
Mailing Address - Phone:949-270-2100
Mailing Address - Fax:949-650-6976
Practice Address - Street 1:331 W. HALESWORTH AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:949-270-2100
Practice Address - Fax:949-650-6976
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily