Provider Demographics
NPI:1144623513
Name:SUH, EUN JUNG
Entity type:Individual
Prefix:
First Name:EUN JUNG
Middle Name:
Last Name:SUH
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 1:101 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1634
Mailing Address - Country:US
Mailing Address - Phone:315-853-5532
Mailing Address - Fax:315-853-1003
Practice Address - Street 1:101 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1634
Practice Address - Country:US
Practice Address - Phone:315-853-5532
Practice Address - Fax:315-853-1003
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04393633Medicaid