Basic Information
| Provider Information | |||||||||
| NPI: | 1548529993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KU | ||||||||
| FirstName: | SUET YING | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KU | ||||||||
| OtherFirstName: | SHARON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2012 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/13/2019 | ||||||||
| NPIReactivationDate: | 05/11/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 998135 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.