Healthcare Provider Details

I. General information

NPI: 1629116306
Provider Name (Legal Business Name): SUSAN GAY BLAIR-BUCKLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 GOLF COURSE RD NW STE D
ALBUQUERQUE NM
87120-5842
US

IV. Provider business mailing address

4340 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-1234
US

V. Phone/Fax

Practice location:
  • Phone: 505-800-7070
  • Fax:
Mailing address:
  • Phone: 505-252-0599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2006-0025
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2006-0025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: