Provider Demographics
NPI:1205835014
Name:BUSSERT, SUSAN K
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:BUSSERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-1342
Mailing Address - Country:US
Mailing Address - Phone:509-882-3500
Mailing Address - Fax:509-882-2392
Practice Address - Street 1:222 E 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1342
Practice Address - Country:US
Practice Address - Phone:509-882-3500
Practice Address - Fax:509-882-2392
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8352015Medicaid
WAAB06525Medicare ID - Type Unspecified
WA8352015Medicaid