Provider Demographics
NPI:1003835885
Name:PATTERSON, SUSAN B (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:STE 104
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-969-6404
Practice Address - Fax:601-973-4541
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR671975363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121347Medicaid
MS512I500463Medicare PIN
MS500000548Medicare ID - Type Unspecified
MS00121347Medicaid
MSS89769Medicare UPIN
MSP00698261Medicare PIN