Provider Demographics
NPI:1912973611
Name:TREBON, SUSAN GERALDINE (PAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GERALDINE
Last Name:TREBON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1920 TITUS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2144
Mailing Address - Country:US
Mailing Address - Phone:619-846-8704
Mailing Address - Fax:619-795-1985
Practice Address - Street 1:35000 GUADACANAL STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-4082
Practice Address - Fax:619-524-0852
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17001OtherPHYSICAN ASSISTANT LICENS