Provider Demographics
NPI:1801385026
Name:TAMAYO, SUSANA J
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:J
Last Name:TAMAYO
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 1:3190 DAVID ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4250
Mailing Address - Country:US
Mailing Address - Phone:714-272-1601
Mailing Address - Fax:
Practice Address - Street 1:3190 DAVID ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4250
Practice Address - Country:US
Practice Address - Phone:714-272-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X247200000X
CA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other