Provider Demographics
NPI:1932304623
Name:O'NEAL, EMILY SUSANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:SUSANNE
Last Name:O'NEAL
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 1:1580 CREEKSIDE DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3886
Mailing Address - Country:US
Mailing Address - Phone:916-984-7870
Mailing Address - Fax:
Practice Address - Street 1:1580 CREEKSIDE DR
Practice Address - Street 2:SUITE 260
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3886
Practice Address - Country:US
Practice Address - Phone:916-984-7870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19209OtherCA PA LICENSE