Healthcare Provider Details

I. General information

NPI: 1720571763
Provider Name (Legal Business Name): MAN HSUAN MELANY SU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3600
US

IV. Provider business mailing address

PO BOX 158
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7218
  • Fax: 505-426-3492
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-747-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018018320
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301503639
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2022-0326
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: