Provider Demographics
NPI:1417167321
Name:THIVIERGE, SUSAN DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DAWN
Last Name:THIVIERGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:MT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-0489
Mailing Address - Country:US
Mailing Address - Phone:903-822-3076
Mailing Address - Fax:903-822-3079
Practice Address - Street 1:8701 NEW TRAILS DR
Practice Address - Street 2:STE. 150
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-4253
Practice Address - Country:US
Practice Address - Phone:281-367-1015
Practice Address - Fax:281-367-1966
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02528363A00000X
IA001984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant