Healthcare Provider Details

I. General information

NPI: 1982928735
Provider Name (Legal Business Name): SUSAN BENTON SULESKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN B JEFFERIES

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 S SEMINOLE TRL
MADISON VA
22727-2690
US

IV. Provider business mailing address

PO BOX 21975
BELFAST ME
04915-4116
US

V. Phone/Fax

Practice location:
  • Phone: 540-948-6871
  • Fax: 540-948-6601
Mailing address:
  • Phone: 540-321-4281
  • Fax: 540-321-4282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-003217
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: