Provider Demographics
NPI:1306820782
Name:MCCONNELL, SUSAN DEANNA (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DEANNA
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:504 RED BANKS RD STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5766
Mailing Address - Country:US
Mailing Address - Phone:252-321-3579
Mailing Address - Fax:252-321-3576
Practice Address - Street 1:504 RED BANKS RD STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5766
Practice Address - Country:US
Practice Address - Phone:252-321-3579
Practice Address - Fax:252-321-3576
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306820782OtherNPI
S95593Medicare UPIN