MEDICARE: MRS. SUSAN THURSTON 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	PA2469	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982736120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN THURSTON PA

Provider Business Mailing Address
First Line	:	3300 S FISKE BLVD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-4306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1855 KNOX MCRAE DR
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-5492
Country	:	US
Telephone Number	:	321-269-2028
Fax Number	:	321-264-0730

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

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	03/16/2020

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