1467647115 NPI number — SUSAN M. MIX FNP

Table of content: SUSAN M. MIX FNP (NPI 1467647115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467647115 NPI number — SUSAN M. MIX FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIX
Provider First Name:
SUSAN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467647115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 GOLF VIEW DRIVE
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-618-4400
Provider Business Mailing Address Fax Number:
541-618-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 GOLF VIEW DRIVE
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-618-4400
Provider Business Practice Location Address Fax Number:
541-618-4406
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  200750116NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 227698 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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