Provider Demographics
NPI:1093752230
Name:HALLORAN, SUSAN J (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:HALLORAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 DAYTON AVE
Mailing Address - Street 2:#109
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6206
Mailing Address - Country:US
Mailing Address - Phone:651-698-0891
Mailing Address - Fax:
Practice Address - Street 1:1619 DAYTON AVE
Practice Address - Street 2:#109
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6206
Practice Address - Country:US
Practice Address - Phone:651-698-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1075937363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN337140900Medicaid
MN337140900Medicaid
P15647Medicare UPIN