Provider Demographics
NPI:1154621449
Name:GALLARDO, SUSAN D (CRNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:D
Last Name:GALLARDO
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Gender:F
Credentials:CRNP
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Mailing Address - Street 1:900 WALNUT STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-955-7000
Mailing Address - Fax:215-923-3504
Practice Address - Street 1:900 WALNUT STREET
Practice Address - Street 2:THOMAS JEFFERSON UNIVERSITY PHYSICIANS SUITE 200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-6939
Practice Address - Fax:215-503-2990
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2014-04-14
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Provider Licenses
StateLicense IDTaxonomies
PASP010847163WN0800X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102886280Medicaid
329180Medicare PIN