Healthcare Provider Details

I. General information

NPI: 1629050513
Provider Name (Legal Business Name): SUSAN LARYSSA EPPERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 IRELAND AVE MEDDAC BLDG 851 RM N1A-53
FORT KNOX KY
40121-5111
US

IV. Provider business mailing address

289 IRELAND AVE MEDDAC BLDG 851 RM N1A-53
FORT KNOX KY
40121-5111
US

V. Phone/Fax

Practice location:
  • Phone: 502-624-0250
  • Fax: 502-624-0443
Mailing address:
  • Phone: 502-624-0250
  • Fax: 502-624-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA175
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: