Provider Demographics
NPI:1255527495
Name:PISTOLE, SUZZANE ROENA (PA-C)
Entity type:Individual
Prefix:
First Name:SUZZANE
Middle Name:ROENA
Last Name:PISTOLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUZZANE
Other - Middle Name:ROENA
Other - Last Name:SIMS/KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7951 SHOAL CREEK BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7582
Mailing Address - Country:US
Mailing Address - Phone:512-584-8404
Mailing Address - Fax:
Practice Address - Street 1:1509 STONECREEK DR S
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147
Practice Address - Country:US
Practice Address - Phone:740-653-2500
Practice Address - Fax:740-653-2552
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0122840Medicaid
H335320Medicare PIN