Healthcare Provider Details

I. General information

NPI: 1073522447
Provider Name (Legal Business Name): SUSAN K FAJARDO R.P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 LONG ST
SHAWNEE KS
66216-2559
US

IV. Provider business mailing address

PO BOX 12066
KANSAS CITY KS
66112-0066
US

V. Phone/Fax

Practice location:
  • Phone: 913-631-6400
  • Fax: 913-631-6868
Mailing address:
  • Phone: 913-299-4966
  • Fax: 913-299-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-00554
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: