Provider Demographics
NPI:1083726681
Name:SUTTLE, RICHARD W (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:SUTTLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2238
Mailing Address - Country:US
Mailing Address - Phone:734-927-0009
Mailing Address - Fax:734-927-0009
Practice Address - Street 1:725 S ADAMS RD
Practice Address - Street 2:#243
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6902
Practice Address - Country:US
Practice Address - Phone:248-220-1148
Practice Address - Fax:248-220-1151
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001147OtherP.A.. LICENSE
MI700H231390OtherBCBS GROUP NUMBER
MIQ72647Medicare UPIN
MI0P47270Medicare PIN