Provider Demographics
NPI:1760462485
Name:MERRILL, SUSAN ELLEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELLEN
Last Name:MERRILL
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 1:6911-100 SHANNON WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226
Mailing Address - Country:US
Mailing Address - Phone:704-529-4101
Mailing Address - Fax:704-529-6655
Practice Address - Street 1:6911-100 SHANNON WILLOW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226
Practice Address - Country:US
Practice Address - Phone:704-529-4101
Practice Address - Fax:704-529-6655
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1016582363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101095Medicaid
1016582OtherNCCPA
NC101951OtherNC LIC #
MM1023629OtherDEA
2749000AMedicare PIN