Provider Demographics
NPI:1790932168
Name:SMITH, SUSAN JAYNE (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JAYNE
Last Name:SMITH
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 1:7020 S 500 W
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:IN
Mailing Address - Zip Code:46571-9577
Mailing Address - Country:US
Mailing Address - Phone:260-593-2099
Mailing Address - Fax:269-695-0412
Practice Address - Street 1:1045 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-8474
Practice Address - Country:US
Practice Address - Phone:269-695-5540
Practice Address - Fax:269-695-0412
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant