Provider Demographics
NPI:1659635829
Name:FERGUSON, SUSAN RENE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENE
Last Name:FERGUSON
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 1:417A RACETRACK RD NW STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4604
Mailing Address - Country:US
Mailing Address - Phone:850-863-5990
Mailing Address - Fax:850-862-0041
Practice Address - Street 1:141 MACK BAYOU LOOP STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7194
Practice Address - Country:US
Practice Address - Phone:850-863-5990
Practice Address - Fax:850-862-0041
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106360363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHM4JXOtherBCBSFL