Healthcare Provider Details

I. General information

NPI: 1528271467
Provider Name (Legal Business Name): SUSAN LYNN CUCCIARDI PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 NW MYHRE PL
SILVERDALE WA
98383-8561
US

IV. Provider business mailing address

2011 NW MYHRE PL
SILVERDALE WA
98383-8561
US

V. Phone/Fax

Practice location:
  • Phone: 360-830-1706
  • Fax:
Mailing address:
  • Phone: 360-830-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.60427957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: