Provider Demographics
NPI:1699806851
Name:FARMER, SUZANNA RENNE (PA)
Entity Type:Individual
Prefix:
First Name:SUZANNA
Middle Name:RENNE
Last Name:FARMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUZANNA
Other - Middle Name:RENNE
Other - Last Name:RITCHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1125 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4514
Mailing Address - Country:US
Mailing Address - Phone:817-810-9810
Mailing Address - Fax:817-810-9815
Practice Address - Street 1:1125 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4514
Practice Address - Country:US
Practice Address - Phone:817-810-9810
Practice Address - Fax:817-810-9815
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPATEMP363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201348401Medicaid
TX201348401Medicaid