Provider Demographics
NPI:1629050513
Name:EPPERSON, SUSAN LARYSSA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LARYSSA
Last Name:EPPERSON
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 1:289 IRELAND AVE
Mailing Address - Street 2:MEDDAC BLDG 851 RM N1A-53
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5111
Mailing Address - Country:US
Mailing Address - Phone:502-624-0250
Mailing Address - Fax:502-624-0443
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:MEDDAC BLDG 851 RM N1A-53
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-0250
Practice Address - Fax:502-624-0443
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA175OtherKENTUCKY CERTIFICATION
1024552OtherNCCPA CERTIFICATE NUMBER