1932110285 NPI number — MRS. SUSAN DECOSTANZA MARCHAND PA C

Table of content: MRS. SUSAN DECOSTANZA MARCHAND PA C (NPI 1932110285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932110285 NPI number — MRS. SUSAN DECOSTANZA MARCHAND PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCHAND
Provider First Name:
SUSAN
Provider Middle Name:
DECOSTANZA
Provider Name Prefix Text:
MRS.
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:
DECOSTANZA
Provider Other First Name:
SUSAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932110285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3311 NW 29TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32605-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-338-1730
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 NW 76TH DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32607-1593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-332-4051
Provider Business Practice Location Address Fax Number:
352-332-2966
Provider Enumeration Date:
08/11/2006

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:  PA9100966 , 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)





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