Provider Demographics
NPI:1023001179
Name:MACOMBER, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6049 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 BELLEVUE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618
Practice Address - Country:US
Practice Address - Phone:609-396-4700
Practice Address - Fax:609-396-4900
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR05001400367500000X
PARN194708L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ018462A3RMedicare ID - Type Unspecified