Provider Demographics
NPI:1447329495
Name:DANSEREAU, SUZANNE (MD LAC)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:DANSEREAU
Suffix:
Gender:F
Credentials:MD LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-9100
Mailing Address - Country:US
Mailing Address - Phone:828-484-9032
Mailing Address - Fax:
Practice Address - Street 1:6 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28787-9100
Practice Address - Country:US
Practice Address - Phone:828-484-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201001898207Q00000X
KY28352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7116Medicaid
NCNCC094AMedicare UPIN
NC7116Medicaid
KY64283526Medicaid
KY0254411Medicare ID - Type Unspecified