Basic Information
| Provider Information | |||||||||
| NPI: | 1033312244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECRUZ | ||||||||
| FirstName: | SUZZUNNE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 INDIAN RIVER ROAD | ||||||||
| Address2: | SUITE A5 | ||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037991252 | ||||||||
| FaxNumber: | 2037993252 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 INDIAN RIVER ROAD | ||||||||
| Address2: | A5 | ||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037991252 | ||||||||
| FaxNumber: | 2037993252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001433 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 001433 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.