Provider Demographics
NPI:1043385487
Name:MERITHEW, SUZZANNE L (PA)
Entity Type:Individual
Prefix:
First Name:SUZZANNE
Middle Name:L
Last Name:MERITHEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGHLAND ST STE 123
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-3881
Mailing Address - Country:US
Mailing Address - Phone:617-696-3411
Mailing Address - Fax:617-696-3499
Practice Address - Street 1:100 HIGHLAND ST STE 123
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3881
Practice Address - Country:US
Practice Address - Phone:617-296-2222
Practice Address - Fax:617-296-3834
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA590363AM0700X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS11636Medicare UPIN
MAAP0162Medicare ID - Type Unspecified