Provider Demographics
NPI:1356302731
Name:HERDMAN, SUSAN KALISTER (PAC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KALISTER
Last Name:HERDMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11325 FALLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4232
Mailing Address - Country:US
Mailing Address - Phone:281-890-7773
Mailing Address - Fax:
Practice Address - Street 1:11325 FALLBROOK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4232
Practice Address - Country:US
Practice Address - Phone:281-890-7773
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B4808Medicare ID - Type Unspecified
TXR59547Medicare UPIN