1912907981 NPI number — SUSAN K RETZLAFF DEITRICK PA-C

Table of content: SUSAN K RETZLAFF DEITRICK PA-C (NPI 1912907981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912907981 NPI number — SUSAN K RETZLAFF DEITRICK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RETZLAFF DEITRICK
Provider First Name:
SUSAN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1912907981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5436
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68802-5436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-9300
Provider Business Mailing Address Fax Number:
484-359-8909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 N WEBB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-4045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-382-1100
Provider Business Practice Location Address Fax Number:
308-385-0796
Provider Enumeration Date:
07/29/2005

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: 363A00000X , with the licence number:  829 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37315 . This is a "BCBS OF NE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 100250168 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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