Healthcare Provider Details

I. General information

NPI: 1720100381
Provider Name (Legal Business Name): SUSAN K BICKNELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 METRO AIRPORT CENTER DR SUITE 104
ROMULUS MI
48174-1456
US

IV. Provider business mailing address

5080 SPECTRUM DR SUITE 1200 WEST
ADDISON TX
75001-4648
US

V. Phone/Fax

Practice location:
  • Phone: 734-955-7000
  • Fax: 734-955-7006
Mailing address:
  • Phone: 972-364-8000
  • Fax: 214-775-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002574
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: