Provider Demographics
NPI:1376696161
Name:MCINTIRE, SUSAN KATHLEEN (PAAA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:MCINTIRE
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6649 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2354
Mailing Address - Country:US
Mailing Address - Phone:770-968-9978
Mailing Address - Fax:770-968-9975
Practice Address - Street 1:6649 LAKE DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2354
Practice Address - Country:US
Practice Address - Phone:770-968-9978
Practice Address - Fax:770-968-9975
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002446367H00000X
SC8367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR12313Medicare UPIN
GA32BBBMVMedicare ID - Type UnspecifiedMEDICARE