Provider Demographics
NPI:1104868256
Name:FAIR, SUSAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:FAIR
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 1:24 WOODWARD AVE
Mailing Address - Street 2:UNIT 61
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-3659
Mailing Address - Country:US
Mailing Address - Phone:203-467-8440
Mailing Address - Fax:
Practice Address - Street 1:175 SHERMAN AVE
Practice Address - Street 2:FIFTH FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4301
Practice Address - Country:US
Practice Address - Phone:203-789-3392
Practice Address - Fax:203-789-5174
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant