Provider Demographics
NPI:1982736120
Name:THURSTON, SUSAN (PA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:THURSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1855 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5492
Practice Address - Country:US
Practice Address - Phone:321-269-2028
Practice Address - Fax:321-264-0730
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLU0313XMedicare PIN
FLP83812Medicare UPIN