Provider Demographics
NPI:1790809739
Name:BERTELSEN, SUSAN BEYER (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BEYER
Last Name:BERTELSEN
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 1:3955 DUNCAN PL
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-4551
Mailing Address - Country:US
Mailing Address - Phone:650-493-6630
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST STE 900
Practice Address - Street 2:CEP - MEDAMERICA PROVIDER ENROLLMENT
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1844
Practice Address - Country:US
Practice Address - Phone:510-350-2676
Practice Address - Fax:510-879-9100
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11214OtherPHYSICIAN'S ASSISTANT