Provider Demographics
NPI:1902196983
Name:BUNTEN, SUSAN LOREE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOREE
Last Name:BUNTEN
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 1:3710 CESAR CHAVEZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-2011
Mailing Address - Country:US
Mailing Address - Phone:323-980-8404
Mailing Address - Fax:323-980-8405
Practice Address - Street 1:3710 CESAR CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2001
Practice Address - Country:US
Practice Address - Phone:323-980-8404
Practice Address - Fax:323-980-8405
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13869363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical