Basic Information
| Provider Information | |||||||||
| NPI: | 1629302542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RACZ | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RACZ | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6301 GASTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752143922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148273610 | ||||||||
| FaxNumber: | 2144439640 | ||||||||
| Practice Location | |||||||||
| Address1: | 6080 N CENTRAL EXPY STE 100 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752065202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148273610 | ||||||||
| FaxNumber: | 2144439640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2009 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00805 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00805 | 01 | TX | TEXAS STATE BOARD LICENSE NUMBER | OTHER |