Provider Demographics
NPI:1699512590
Name:SUN, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6742 BLUE POINT DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-3419
Mailing Address - Country:US
Mailing Address - Phone:760-855-8625
Mailing Address - Fax:
Practice Address - Street 1:9460 CUYAMACA ST STE 104
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-5921
Practice Address - Country:US
Practice Address - Phone:619-569-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1220622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant