Provider Demographics
NPI:1730303579
Name:SUTTILE, PETER D JR (MS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:D
Last Name:SUTTILE
Suffix:JR
Gender:M
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BURNET CRESCENT
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691
Mailing Address - Country:US
Mailing Address - Phone:609-258-3141
Mailing Address - Fax:609-258-1355
Practice Address - Street 1:PRINCETON UNIVERSITY HEALTH SERVICE
Practice Address - Street 2:WASHINGTON ROAD- MCCOSH HEALTH CTR.
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08544-1004
Practice Address - Country:US
Practice Address - Phone:609-258-3141
Practice Address - Fax:609-258-1355
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00000500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00000500OtherLICENCE