1417167321 NPI number — SUSAN DAWN THIVIERGE PA-C

Table of content: SUSAN DAWN THIVIERGE PA-C (NPI 1417167321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417167321 NPI number — SUSAN DAWN THIVIERGE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIVIERGE
Provider First Name:
SUSAN
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417167321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT ENTERPRISE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75681-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-822-3076
Provider Business Mailing Address Fax Number:
903-822-3079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8701 NEW TRAILS DR
Provider Second Line Business Practice Location Address:
STE. 150
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77381-4253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-367-1015
Provider Business Practice Location Address Fax Number:
281-367-1966
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA02528 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 001984 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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