Provider Demographics
NPI:1861420341
Name:WASSENHOVE, SUSAN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WASSENHOVE
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 1:812 W 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544
Mailing Address - Country:US
Mailing Address - Phone:574-255-1604
Mailing Address - Fax:
Practice Address - Street 1:812 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1738
Practice Address - Country:US
Practice Address - Phone:574-255-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1722207Q00000X
MI5601001412363A00000X
WI2692-23,363A00000X
AZ4398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP38340020Medicare Oscar/Certification
WIP00878157Medicare Oscar/Certification
WI087450055Medicare Oscar/Certification