MEDICARE: SUZANNE ELLETT PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA05602	TX

General Provider Information

NPI Number	:	1568647576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE ELLETT PA

Provider Business Mailing Address
First Line	:	2005 FORT WORTH HWY STE 200
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4781
Country	:	US
Telephone Number	:	817-599-7661
Fax Number	:	817-599-8408

Provider Business Practice Location Address
First Line	:	2005 FORT WORTH HWY STE 200
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4781
Country	:	US
Telephone Number	:	817-599-7661
Fax Number	:	817-599-8408

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2008
Last Update Date	:	10/20/2015

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Directions to “ SUZANNE ELLETT PA” Practice Location

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