Provider Demographics
NPI:1760422653
Name:WOLF, SUSAN JANE (PAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:WOLF
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N WOLFE ST
Mailing Address - Street 2:WILMER ROOM 340
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-9030
Mailing Address - Country:US
Mailing Address - Phone:410-955-5730
Mailing Address - Fax:410-614-0316
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:WILMER ROOM 340
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-9030
Practice Address - Country:US
Practice Address - Phone:410-955-5730
Practice Address - Fax:410-614-0316
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant