Provider Demographics
NPI:1790727410
Name:METTILLE, SUSAN M (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:METTILLE
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 1:2805 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-624-9400
Mailing Address - Fax:309-624-2280
Practice Address - Street 1:2805 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-624-9400
Practice Address - Fax:309-624-2280
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE - GROUP #
IL208846OtherMEDICARE GROUP #
ILK05923Medicare PIN
IL208846OtherMEDICARE GROUP #
ILQ13529Medicare UPIN