Basic Information
| Provider Information | |||||||||
| NPI: | 1285176859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JARADAT | ||||||||
| FirstName: | SUZAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 CENTRAL AVE SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057246124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2016 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | RS2016-0953 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD2020-0771 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.