Provider Demographics
NPI:1053631523
Name:SYTY, SUSAN (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SYTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SHADLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 598
Mailing Address - Street 2:
Mailing Address - City:HARWICH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02646-0598
Mailing Address - Country:US
Mailing Address - Phone:508-432-1400
Mailing Address - Fax:
Practice Address - Street 1:710 ROUTE 28
Practice Address - Street 2:
Practice Address - City:HARWICH PORT
Practice Address - State:MA
Practice Address - Zip Code:02646-1931
Practice Address - Country:US
Practice Address - Phone:508-432-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054377363A00000X
MAPA8941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant