MEDICARE: MS. SUSAN LARYSSA EPPERSON PA-C

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	PA175	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA175	OTHER	KY	KENTUCKY CERTIFICATION
2	1024552	OTHER		NCCPA CERTIFICATE NUMBER

General Provider Information

NPI Number	:	1629050513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN LARYSSA EPPERSON PA-C

Provider Business Mailing Address
First Line	:	289 IRELAND AVE
Second Line	:	MEDDAC BLDG 851 RM N1A-53
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5111
Country	:	US
Telephone Number	:	502-624-0250
Fax Number	:	502-624-0443

Provider Business Practice Location Address
First Line	:	289 IRELAND AVE
Second Line	:	MEDDAC BLDG 851 RM N1A-53
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5111
Country	:	US
Telephone Number	:	502-624-0250
Fax Number	:	502-624-0443

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	09/23/2008

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