Provider Demographics
NPI:1548283013
Name:ANDERSON, SUSAN C (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:ANDERSON
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-862-4325
Mailing Address - Fax:607-862-9006
Practice Address - Street 1:2352 STATE ROUTE 26
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-6418
Practice Address - Country:US
Practice Address - Phone:607-862-4325
Practice Address - Fax:607-862-9006
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02923944Medicaid
NYPA2705Medicare PIN
VTS96986Medicare UPIN