Provider Demographics
NPI:1376503623
Name:JOHNSON, SUSANNE T (PAC)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:T
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5228 W PLANO PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5005
Mailing Address - Country:US
Mailing Address - Phone:972-250-5700
Mailing Address - Fax:972-250-5651
Practice Address - Street 1:5228 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5005
Practice Address - Country:US
Practice Address - Phone:972-250-5700
Practice Address - Fax:972-250-5651
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K1872Medicare PIN