Healthcare Provider Details

I. General information

NPI: 1528064060
Provider Name (Legal Business Name): SUSAN FAYTHE GOWING P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN FAYTHE PADILLA

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE SUITE 405
LAS CRUCES NM
88011-8259
US

IV. Provider business mailing address

1923 WINDSOR PL
LAS CRUCES NM
88005-1683
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-0121
  • Fax: 575-532-5949
Mailing address:
  • Phone: 575-312-9077
  • Fax: 575-647-2938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number78-PA003
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: