Healthcare Provider Details

I. General information

NPI: 1477613891
Provider Name (Legal Business Name): SUSAN DIANE EARLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN D TWILLEY

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SAINT MICHAELS DR
SANTA FE NM
87505-7670
US

IV. Provider business mailing address

465 SAINT MICHAELS DR
SANTA FE NM
87505-7670
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-3233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10005131
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2005-0049
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: