Healthcare Provider Details

I. General information

NPI: 1104152966
Provider Name (Legal Business Name): NINA GLORIA SUH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18564 US HIGHWAY 18 STE 103104
APPLE VALLEY CA
92307-2312
US

IV. Provider business mailing address

19111 TOWN CENTER DR
APPLE VALLEY CA
92308-8989
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-9262
  • Fax:
Mailing address:
  • Phone: 760-242-7777
  • Fax: 760-242-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number20596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: