Provider Demographics
NPI:1255392908
Name:MAILLE, SUSAN A (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:MAILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:500 SCOTT ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5613
Practice Address - Country:US
Practice Address - Phone:570-829-7870
Practice Address - Fax:570-829-7938
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001880L363A00000X
PAOA000939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S69805Medicare UPIN
PA022677Medicare ID - Type Unspecified