Provider Demographics
NPI:1366497703
Name:PAK, SUSAN G (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:PAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:909-796-4158
Practice Address - Street 1:81 HIGHLAND SPRINGS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223
Practice Address - Country:US
Practice Address - Phone:951-845-0313
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA14449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA144490Medicaid
CAP02354Medicare UPIN