Provider Demographics
NPI:1932187952
Name:SMITH, SUZANNE M (PA-C)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 NEW VISION DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1716
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000320A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970006353OtherRR MEDICARE
IN047840BBBMedicare ID - Type Unspecified
INS81561Medicare UPIN