Provider Demographics
NPI:1164415246
Name:AUGUSTUS, SUSAN JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:AUGUSTUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JEAN
Other - Last Name:PETTEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:795 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-1733
Mailing Address - Country:US
Mailing Address - Phone:508-235-5258
Mailing Address - Fax:508-675-5671
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-235-5258
Practice Address - Fax:508-675-5671
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA0002Medicare ID - Type Unspecified