Provider Demographics
NPI:1598547481
Name:SUSAK, IHOR IHOROVYCH
Entity Type:Individual
Prefix:
First Name:IHOR
Middle Name:IHOROVYCH
Last Name:SUSAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4331
Mailing Address - Country:US
Mailing Address - Phone:904-222-6656
Mailing Address - Fax:904-222-6657
Practice Address - Street 1:3900 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4331
Practice Address - Country:US
Practice Address - Phone:904-222-6656
Practice Address - Fax:904-222-6667
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty