Provider Demographics
NPI:1750675526
Name:WITTLICH, SUSAN MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:WITTLICH
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:13131 TESSON FERRY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3887
Mailing Address - Country:US
Mailing Address - Phone:314-756-8035
Mailing Address - Fax:314-756-8050
Practice Address - Street 1:13131 TESSON FERRY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3887
Practice Address - Country:US
Practice Address - Phone:314-756-8035
Practice Address - Fax:314-756-8050
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2015-04-15
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Provider Licenses
StateLicense IDTaxonomies
MO111398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant