Provider Demographics
NPI:1578683082
Name:KENT, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:KENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SURREY
Other - Middle Name:
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2645 OLD SAN JOSE RD
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9726
Mailing Address - Country:US
Mailing Address - Phone:831-477-9069
Mailing Address - Fax:
Practice Address - Street 1:2645 OLD SAN JOSE RD
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-9726
Practice Address - Country:US
Practice Address - Phone:831-477-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10537363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical