Provider Demographics
NPI:1861676553
Name:BAKKE, SUZANNE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:BAKKE
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 1:84 SANTA ROSA ST
Mailing Address - Street 2:STE A
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1812
Mailing Address - Country:US
Mailing Address - Phone:805-591-4727
Mailing Address - Fax:
Practice Address - Street 1:84 SANTA ROSA ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5816
Practice Address - Country:US
Practice Address - Phone:805-591-4727
Practice Address - Fax:805-439-3394
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEV844ZMedicare PIN