Provider Demographics
NPI:1073522447
Name:FAJARDO, SUSAN K (RPAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12066
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-0066
Mailing Address - Country:US
Mailing Address - Phone:913-299-4966
Mailing Address - Fax:913-299-4205
Practice Address - Street 1:6345 LONG ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-2559
Practice Address - Country:US
Practice Address - Phone:913-631-6400
Practice Address - Fax:913-631-6868
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ65475Medicare UPIN
MOC47E412AMedicare ID - Type Unspecified