Provider Demographics
NPI:1407998768
Name:DANIELS, SUSAN L (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7333 LEE HWY STE C
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-8001
Mailing Address - Country:US
Mailing Address - Phone:423-499-8877
Mailing Address - Fax:423-499-8085
Practice Address - Street 1:7333 LEE HWY STE C
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-8001
Practice Address - Country:US
Practice Address - Phone:423-499-8877
Practice Address - Fax:423-499-8085
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP73234Medicare UPIN
MI0M52870062Medicare ID - Type Unspecified