Provider Demographics
NPI:1316021777
Name:VILLALOBOS, SUZANNE ELAINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:ELAINE
Last Name:VILLALOBOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1230 SKY LN
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2385
Mailing Address - Country:US
Mailing Address - Phone:386-943-8463
Mailing Address - Fax:386-822-8152
Practice Address - Street 1:549 N BERT FISH DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-3509
Practice Address - Country:US
Practice Address - Phone:386-822-8150
Practice Address - Fax:386-822-8152
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001638300Medicaid
FLCG512YMedicare PIN