Provider Demographics
NPI:1427325562
Name:PERSAUD, SURITA D (C)
Entity type:Individual
Prefix:MS
First Name:SURITA
Middle Name:D
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11688 SW ERROL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4046
Mailing Address - Country:US
Mailing Address - Phone:971-777-0675
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURE2288163W00000X
NY5681501367500000X
OR201910314RN367500000X
GUNP0171367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5681501Medicare PIN