Provider Demographics
NPI:1780648329
Name:BOYD, SUSANNE LYN (PA)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:LYN
Last Name:BOYD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4625
Mailing Address - Country:US
Mailing Address - Phone:616-940-0238
Mailing Address - Fax:616-281-0250
Practice Address - Street 1:4540 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4625
Practice Address - Country:US
Practice Address - Phone:616-940-0238
Practice Address - Fax:616-281-0250
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S54194Medicare UPIN
MIMI2875006Medicare PIN