Provider Demographics
NPI:1366539652
Name:FERNBACH, SUZANNE MICHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MICHELLE
Last Name:FERNBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:M
Other - Last Name:BIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-903-0268
Mailing Address - Fax:889-428-1444
Practice Address - Street 1:405 VIOLET RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8956
Practice Address - Country:US
Practice Address - Phone:859-903-0268
Practice Address - Fax:859-428-1444
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002914A363A00000X
KYPA646363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002804Medicaid
KY0389249Medicare PIN
KY95002804Medicaid
KY0231235Medicare PIN