Provider Demographics
NPI:1093898645
Name:EGAN, SUSAN MARIE (MSN,FNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:EGAN
Suffix:
Gender:F
Credentials:MSN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MORRISSEY DR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4395
Mailing Address - Country:US
Mailing Address - Phone:262-741-1900
Mailing Address - Fax:262-741-1743
Practice Address - Street 1:201 E MORRISSEY DR
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4395
Practice Address - Country:US
Practice Address - Phone:262-741-1900
Practice Address - Fax:262-741-1743
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI405363LF0000X
IL209-005034363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43821700Medicaid
71480-0127Medicare ID - Type Unspecified
WI43821700Medicaid
WIK400350781Medicare PIN
IL962341Medicare PIN