Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 4594 | NM |
N | 2251X0800X | Physical Therapist - Orthopedic | 4594 | NM |
NPI | 1124410519 |
---|---|
Provider Name | Dr. Susanna (sunel) P Van Der Walt |
First Address | Placitas, NM 87043-8760 |
Second Address | Albuquerque, NM 87109-3588 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2015 |
Last Update Date | 01/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10171568 | (05) | NM |
326556 | MEDICARE (01) | NM |