Healthcare Provider Details

I. General information

NPI: 1467969014
Provider Name (Legal Business Name): PHILIP SUH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 12/09/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 US HIGHWAY 18
APPLE VALLEY CA
92307-2206
US

IV. Provider business mailing address

1473 DEER HOLLOW DR
CORONA CA
92882-6069
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-2311
  • Fax:
Mailing address:
  • Phone: 909-855-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: