Provider Demographics
NPI:1235133067
Name:MILBACH, SUSAN M (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MILBACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1323
Mailing Address - Country:US
Mailing Address - Phone:253-503-2598
Mailing Address - Fax:253-682-2427
Practice Address - Street 1:34503 9TH AVE S
Practice Address - Street 2:SUITE 240
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8727
Practice Address - Country:US
Practice Address - Phone:253-838-9839
Practice Address - Fax:253-661-9077
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60089224367500000X
VA0024164185367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8885531OtherPTAN (N)
WAG8885532OtherPTAN (S)
VA008933448Medicaid
VA430058704Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
VA008933448Medicaid