Provider Demographics
NPI:1730223637
Name:STACK, SUSANNE C (PA-C)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:C
Last Name:STACK
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:PO BOX 31297
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-3021
Mailing Address - Country:US
Mailing Address - Phone:509-443-1668
Mailing Address - Fax:
Practice Address - Street 1:5206 S STONE LN
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-6524
Practice Address - Country:US
Practice Address - Phone:509-443-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10004295OtherSTATE LICENSE #
WAPA10004295OtherSTATE LICENSE #