1659635829 NPI number — SUSAN RENE FERGUSON PA-C

Table of content: SUSAN RENE FERGUSON PA-C (NPI 1659635829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659635829 NPI number — SUSAN RENE FERGUSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
SUSAN
Provider Middle Name:
RENE
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:
1659635829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417A RACETRACK RD NW STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-4604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-863-5990
Provider Business Mailing Address Fax Number:
850-862-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 MACK BAYOU LOOP STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32459-7194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-863-5990
Provider Business Practice Location Address Fax Number:
850-862-0041
Provider Enumeration Date:
07/02/2012

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: 363AM0700X , with the licence number:  9106360 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017194000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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