Provider Demographics
NPI:1639400138
Name:SMITH, SUSANNE DAY KENAGY (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:DAY KENAGY
Last Name:SMITH
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 1:450 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-3861
Mailing Address - Fax:
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3933363A00000X
CT002973363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1639400138OtherANTHEM BCBS