Provider Demographics
NPI:1003817578
Name:MCKIM, SUSAN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:MCKIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10170 SORRENTO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1604
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-8646
Practice Address - Fax:858-554-6271
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00121500207P00000X
CAPA 15527363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q45638Medicare UPIN