Provider Demographics
NPI:1720100381
Name:BICKNELL, SUSAN K (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:BICKNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:214-775-4502
Practice Address - Street 1:11700 METRO AIRPORT CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1456
Practice Address - Country:US
Practice Address - Phone:734-955-7000
Practice Address - Fax:734-955-7006
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1503035Medicare UPIN
MIMI1503Medicare PIN
MIMI1504035Medicare UPIN
MIMI1504Medicare PIN