Healthcare Provider Details

I. General information

NPI: 1477542371
Provider Name (Legal Business Name): WALTER LO SIA SU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N CENTRA CARE CLINIC
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N CENTRA CARE CLINIC
ST CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-240-2118
Mailing address:
  • Phone: 320-251-2700
  • Fax: 320-240-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37684
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number37684
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: