Provider Demographics
NPI:1477532935
Name:GONGLOFF, SUZANNE M (PA)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:GONGLOFF
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 1:104 SELMA DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3834
Mailing Address - Country:US
Mailing Address - Phone:540-678-2800
Mailing Address - Fax:
Practice Address - Street 1:104 SELMA DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3834
Practice Address - Country:US
Practice Address - Phone:540-678-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001482363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P94546Medicare UPIN
VAP00067676Medicare ID - Type UnspecifiedRAILROAD MEDICARE
VA002262S96Medicare ID - Type UnspecifiedTRAILBLAZERS