Provider Demographics
NPI:1932628450
Name:COYNE, SUSAN O'NEIL (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:O'NEIL
Last Name:COYNE
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 1:92 CAMPUS DR STE C
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7133
Mailing Address - Country:US
Mailing Address - Phone:207-797-5753
Mailing Address - Fax:
Practice Address - Street 1:92 CAMPUS DR FL 3
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7133
Practice Address - Country:US
Practice Address - Phone:207-797-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059270363AS0400X
MEPA2311363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPA2311OtherMAINE STATE CERTIFICATION