Provider Demographics
NPI:1033428057
Name:KUTZ, SUSAN KAYLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAYLEEN
Last Name:KUTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71230
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19176-6230
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:STE 310
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3616
Practice Address - Country:US
Practice Address - Phone:703-810-5215
Practice Address - Fax:703-810-5428
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN