Provider Demographics
NPI:1932110285
Name:MARCHAND, SUSAN DECOSTANZA (PA C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DECOSTANZA
Last Name:MARCHAND
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:DECOSTANZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3311 NW 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2713
Mailing Address - Country:US
Mailing Address - Phone:352-338-1730
Mailing Address - Fax:
Practice Address - Street 1:350 NW 76TH DR
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1593
Practice Address - Country:US
Practice Address - Phone:352-332-4051
Practice Address - Fax:352-332-2966
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
593530Medicare UPIN
E33192Medicare ID - Type Unspecified