Provider Demographics
NPI:1780704510
Name:BONG, SUZANNAH (PA)
Entity type:Individual
Prefix:
First Name:SUZANNAH
Middle Name:
Last Name:BONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:W180N8085 TOWN HALL RD
Mailing Address - Street 2:CMH HEART AND VASCULAR CENTER
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:262-532-1300
Mailing Address - Fax:
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:CMH HEART AND VASCULAR CENTER
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:262-532-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780704510Medicaid
WI41939700Medicaid
WI1780704510Medicaid
Q60137Medicare UPIN
WI001968870Medicare PIN