Provider Demographics
NPI:1730779224
Name:SU, FAN (PT)
Entity type:Individual
Prefix:
First Name:FAN
Middle Name:
Last Name:SU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:SU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1851 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1623
Mailing Address - Country:US
Mailing Address - Phone:626-321-6609
Mailing Address - Fax:
Practice Address - Street 1:7054 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-5117
Practice Address - Country:US
Practice Address - Phone:205-227-7985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH9502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist