Provider Demographics
NPI:1477955870
Name:VANDIVIER, SUZETTE DENISE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:DENISE
Last Name:VANDIVIER
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 1:1124 E ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4052
Mailing Address - Country:US
Mailing Address - Phone:970-484-0798
Mailing Address - Fax:970-482-0679
Practice Address - Street 1:1124 E ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4052
Practice Address - Country:US
Practice Address - Phone:970-484-0798
Practice Address - Fax:970-482-0679
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical