Provider Demographics
NPI:1386734614
Name:DAVIS, SUSAN LYNNE (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNNE
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-1992
Mailing Address - Country:US
Mailing Address - Phone:918-426-2442
Mailing Address - Fax:918-426-0888
Practice Address - Street 1:1429 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:HARTSHORNE
Practice Address - State:OK
Practice Address - Zip Code:74547-3839
Practice Address - Country:US
Practice Address - Phone:918-297-2403
Practice Address - Fax:918-426-0888
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA533363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200047790AMedicaid
Q30471Medicare UPIN
OK200047790AMedicaid
244434402Medicare ID - Type Unspecified