Provider Demographics
NPI:1497766430
Name:SCHOONOVER, SUE C (PAC)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:C
Last Name:SCHOONOVER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:C
Other - Last Name:COLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:301 LAS FLORES AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354
Mailing Address - Country:US
Mailing Address - Phone:209-479-2516
Mailing Address - Fax:209-571-0326
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:#135
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-571-1693
Practice Address - Fax:209-571-0326
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 16766OtherLICENSE NUMBER