Provider Demographics
NPI:1639407950
Name:BARRETT, SUSAN VELLA (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VELLA
Last Name:BARRETT
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 1:24 FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2348
Mailing Address - Country:US
Mailing Address - Phone:973-626-2916
Mailing Address - Fax:
Practice Address - Street 1:55 E 86TH ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1059
Practice Address - Country:US
Practice Address - Phone:212-288-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013522-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant