Healthcare Provider Details

I. General information

NPI: 1750675526
Provider Name (Legal Business Name): SUSAN MICHELLE WITTLICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 VILLAGE SQUARE SHOP CTR
HAZELWOOD MO
63042-1818
US

IV. Provider business mailing address

2436 MIRASOL TRL, EUREKA, MO 63025
EUREKA MO
63025
US

V. Phone/Fax

Practice location:
  • Phone: 636-253-0493
  • Fax:
Mailing address:
  • Phone: 636-253-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number111398
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: