Provider Demographics
NPI:1215252002
Name:PAGON, SUSAN GAYE (LMP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAYE
Last Name:PAGON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SE 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4653
Mailing Address - Country:US
Mailing Address - Phone:360-904-9076
Mailing Address - Fax:
Practice Address - Street 1:104 SE 107TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-4653
Practice Address - Country:US
Practice Address - Phone:360-904-9076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022788172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist