Provider Demographics
NPI:1639299514
Name:BADER, SUSAN (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BADER
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 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-1246
Practice Address - Street 1:450 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1118
Practice Address - Country:US
Practice Address - Phone:516-765-8895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant