Provider Demographics
NPI:1104152966
Name:SUH, NINA GLORIA (PA-C)
Entity type:Individual
Prefix:MS
First Name:NINA
Middle Name:GLORIA
Last Name:SUH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19111 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-8989
Mailing Address - Country:US
Mailing Address - Phone:760-242-7777
Mailing Address - Fax:760-242-2658
Practice Address - Street 1:18564 US HIGHWAY 18 STE 103104
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2312
Practice Address - Country:US
Practice Address - Phone:760-242-9262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20506OtherPHYSICIAN ASSISTANT LICENSE NUMBER