Provider Demographics
NPI:1164740478
Name:WOLLENBURG, SUSAN LEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:WOLLENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7123 S. HARRISON DR. APT 108
Mailing Address - Street 2:
Mailing Address - City:LAVISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128
Mailing Address - Country:US
Mailing Address - Phone:402-239-0028
Mailing Address - Fax:
Practice Address - Street 1:988102 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-7200
Practice Address - Fax:402-559-9344
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant