Provider Demographics
NPI:1497769079
Name:ARDISSON, SUSAN ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:ARDISSON
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 1:1615 BUNKER HILL WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-6013
Mailing Address - Country:US
Mailing Address - Phone:831-769-1304
Mailing Address - Fax:831-757-0291
Practice Address - Street 1:559 E ALISAL ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93905-2516
Practice Address - Country:US
Practice Address - Phone:831-769-8800
Practice Address - Fax:831-422-9312
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70832FMedicaid
CAN9263201OtherDRIVER LICENSE