Provider Demographics
NPI:1285718874
Name:SHIMAITIS, SUZANNE M (PAC)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:SHIMAITIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-4110
Mailing Address - Country:US
Mailing Address - Phone:615-444-2121
Mailing Address - Fax:615-547-6474
Practice Address - Street 1:702 S CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-4110
Practice Address - Country:US
Practice Address - Phone:615-444-2121
Practice Address - Fax:615-547-6474
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769380Medicare PIN
ILK33252Medicare PIN