Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD069929L | PA |
N | 207QA0401X | Family Doctor - Addiction Medicine | 0101250992 | VA |
N | 207QA0401X | Family Doctor - Addiction Medicine | MD069929L | PA |
N | 207QA0505X | Family Doctor - Adult Medicine | 0101250992 | VA |
NPI | 1861488074 |
---|---|
Provider Name | Su Fairchild |
First Address | Bloomsburg, PA 17815-0974 |
Second Address | Centreville, VA 20121-4264 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2005 |
Last Update Date | 10/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001122151 | (05) | PA |
H23826 | (02) |