Provider Demographics
NPI:1871837260
Name:MOAK, SUSAN (RPA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MOAK
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MICHAELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8324 OSWEGO RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1085
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-7039
Practice Address - Street 1:8100 OSWEGO RD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1654
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-9698
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant