Provider Demographics
NPI:1083642821
Name:FRIAR, SUSAN (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FRIAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-0107
Mailing Address - Country:US
Mailing Address - Phone:231-922-9270
Mailing Address - Fax:231-922-9271
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-922-9270
Practice Address - Fax:231-922-9271
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI004062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P92373Medicare UPIN
MIN82810010Medicare PIN