MEDICARE: SUSAN M MCCABE 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	PA20198	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA20198	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1992032643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M MCCABE PA-C

Provider Business Mailing Address
First Line	:	2550 NORTH HOLLYWOOD WAY
Second Line	:	SUITE 204
City	:	BURBANK
State	:	CA
Zip	:	91505-5040
Country	:	US
Telephone Number	:	818-557-0135
Fax Number	:	818-557-1394

Provider Business Practice Location Address
First Line	:	41870 GARSTIN DRIVE
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-1649
Country	:	US
Telephone Number	:	909-878-8214
Fax Number	:	909-878-8282

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

Provider Enumeration Date	:	11/17/2009
Last Update Date	:	11/17/2009

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