Provider Demographics
NPI:1144204173
Name:IVERSON, SUZETTE WIDDISON (MPH PAC)
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:WIDDISON
Last Name:IVERSON
Suffix:
Gender:F
Credentials:MPH PAC
Other - Prefix:
Other - First Name:SUZETTE
Other - Middle Name:
Other - Last Name:WIDDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPHPAC
Mailing Address - Street 1:4700 POINT FOSDICK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-851-5121
Mailing Address - Fax:253-851-3059
Practice Address - Street 1:4700 POINT FOSDICK DR STE 220
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-851-5121
Practice Address - Fax:253-851-3059
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0291728OtherL&I
WA8500191Medicaid
WAG8907654OtherMEDICARE
WA0239348OtherSTATE L&I
8866911Medicare PIN
WAG8875647Medicare PIN
WA8500191Medicaid
WAG8907654OtherMEDICARE