Healthcare Provider Details

I. General information

NPI: 1053631523
Provider Name (Legal Business Name): SUSAN SYTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN SHADLE PA-C

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 ROUTE 28
HARWICH PORT MA
02646-1931
US

IV. Provider business mailing address

PO BOX 598
HARWICH PORT MA
02646-0598
US

V. Phone/Fax

Practice location:
  • Phone: 508-432-1400
  • Fax:
Mailing address:
  • Phone: 508-432-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054377
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8941
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: