Provider Demographics
NPI:1033394283
Name:OKKERSE, SUSAN MALTON (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MALTON
Last Name:OKKERSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:MALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 560727
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-0727
Mailing Address - Country:US
Mailing Address - Phone:704-863-5665
Mailing Address - Fax:
Practice Address - Street 1:8800 NORTH TRYON STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-863-5665
Practice Address - Fax:704-863-5848
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31372367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC182152OtherRN LICENSE
SCNAN540Medicaid
31372OtherAANA LICENSE
NC8051739Medicaid
SCNAN540Medicaid