Provider Demographics
NPI:1992765309
Name:DUNGAN, SUSAN ESCUDERO (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ESCUDERO
Last Name:DUNGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:ESCUDERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 51626
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87181
Mailing Address - Country:US
Mailing Address - Phone:505-263-4222
Mailing Address - Fax:
Practice Address - Street 1:8330 WASHINGTON PL NE
Practice Address - Street 2:A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113
Practice Address - Country:US
Practice Address - Phone:505-345-6289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM326562Medicare ID - Type UnspecifiedGROUP