Provider Demographics
NPI:1417931981
Name:ODONNELL, SUSAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:ODONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2550 MOSSIDE BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3540
Mailing Address - Country:US
Mailing Address - Phone:412-856-2440
Mailing Address - Fax:412-856-4335
Practice Address - Street 1:2550 MOSSIDE BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3540
Practice Address - Country:US
Practice Address - Phone:412-856-2440
Practice Address - Fax:412-856-4335
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002995L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
063181Medicare ID - Type Unspecified
P69202Medicare UPIN