Healthcare Provider Details

I. General information

NPI: 1366539652
Provider Name (Legal Business Name): SUZANNE MICHELLE FERNBACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE M BIRD PA-C

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 VIOLET RD
CRITTENDEN KY
41030-8956
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-903-0268
  • Fax: 859-428-1444
Mailing address:
  • Phone: 859-903-0268
  • Fax: 889-428-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002914A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA646
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA646
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: