Provider Demographics
NPI:1114935152
Name:MATARESE, SUSAN E (PA C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:MATARESE
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 1:2 WINTERCORN CIR
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-1402
Mailing Address - Country:US
Mailing Address - Phone:302-239-9372
Mailing Address - Fax:302-239-9342
Practice Address - Street 1:1200 PEOPLES PLZ
Practice Address - Street 2:SUITE 1285
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-5701
Practice Address - Country:US
Practice Address - Phone:302-832-0880
Practice Address - Fax:302-832-1640
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000315363AM0700X
PAMA002115L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S43854Medicare UPIN
DE011638Medicare ID - Type Unspecified