Provider Demographics
NPI:1467494872
Name:ST. JACQUES, SUSAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ST. JACQUES
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 1:33 N MARK DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-1565
Mailing Address - Country:US
Mailing Address - Phone:203-888-7644
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000445363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS55615Medicare UPIN