Healthcare Provider Details

I. General information

NPI: 1366497703
Provider Name (Legal Business Name): SUSAN G PAK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 HIGHLAND SPRINGS AVE SUITE 200
BEAUMONT CA
92223
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-0313
  • Fax: 909-796-4158
Mailing address:
  • Phone: 909-335-4188
  • Fax: 909-796-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: