Provider Demographics
NPI:1982738712
Name:SU, FANNIE WYNDY (MD)
Entity Type:Individual
Prefix:
First Name:FANNIE
Middle Name:WYNDY
Last Name:SU
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:370 N WIGET LN
Mailing Address - Street 2:STE 210
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2452
Mailing Address - Country:US
Mailing Address - Phone:925-935-6252
Mailing Address - Fax:925-935-7611
Practice Address - Street 1:130 LA CASA VIA
Practice Address - Street 2:BLDG 2 SUITE 209
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3045
Practice Address - Country:US
Practice Address - Phone:925-935-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA85919207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85919OtherSTATE MEDICAL LICENSE
CAA85919OtherSTATE MEDICAL LICENSE