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General NPI Number Information
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NPI Number | 1437449816
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Entity Type | Individual
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Provider Name | SUSAN ELISSA DYMOND PA-C
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Gender | Female
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Dates
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Enumeration Date | 04/19/2011
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 4000 COAST GUARD BLVD
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City | PORTSMOUTH
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State | VA
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Zip | 23703-2135
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Country | US
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Telephone | 757-483-8596
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Fax |
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Provider Business Mailing Address
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Address Line | 300 E MAIN ST STE 1000
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City | NORFOLK
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State | VA
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Zip | 23510-9109
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Country | US
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Telephone | 757-403-3842
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA51745
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License Number State | CA
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