Provider Demographics
NPI:1528271467
Name:CUCCIARDI, SUSAN LYNN (PAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:CUCCIARDI
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 1:2011 NW MYHRE PL
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8561
Mailing Address - Country:US
Mailing Address - Phone:360-830-1600
Mailing Address - Fax:
Practice Address - Street 1:2011 NW MYHRE PL
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8561
Practice Address - Country:US
Practice Address - Phone:360-830-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.60427957363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032800Medicaid