Provider Demographics
NPI:1053373357
Name:SACKETT, SUZANNE HELENE (PA-C, MHS)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:HELENE
Last Name:SACKETT
Suffix:
Gender:F
Credentials:PA-C, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-241-9700
Mailing Address - Fax:
Practice Address - Street 1:1021 BANDANA BLVD E
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5113
Practice Address - Country:US
Practice Address - Phone:651-241-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970001875Medicare ID - Type Unspecified
Q44471Medicare UPIN