1982738712 NPI number — FANNIE WYNDY SU MD

Table of content: LYNNEL C GOODMAN (NPI 1265937692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982738712 NPI number — FANNIE WYNDY SU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SU
Provider First Name:
FANNIE
Provider Middle Name:
WYNDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982738712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 N WIGET LN
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94598-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-935-6252
Provider Business Mailing Address Fax Number:
925-935-7611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 LA CASA VIA
Provider Second Line Business Practice Location Address:
BLDG 2 SUITE 209
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94598-3045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-935-6252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  A85919 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A85919 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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