Healthcare Provider Details

I. General information

NPI: 1104560549
Provider Name (Legal Business Name): MRS. SUJA PETER THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ORLANDO AVE
ALBANY NY
12203-2502
US

IV. Provider business mailing address

18 ORLANDO AVE
ALBANY NY
12203-2502
US

V. Phone/Fax

Practice location:
  • Phone: 518-542-0276
  • Fax:
Mailing address:
  • Phone: 518-542-0276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF310704-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: