Provider Demographics
NPI:1447447628
Name:AHLSTROM, SUSAN MARY (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:AHLSTROM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 W KNOTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-6139
Mailing Address - Country:US
Mailing Address - Phone:520-282-2658
Mailing Address - Fax:
Practice Address - Street 1:1895 W VALENCIA RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-6555
Practice Address - Country:US
Practice Address - Phone:520-576-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9125363A00000X
CAPA18694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant