Provider Demographics
NPI:1275957052
Name:MATHEW, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:Z
Other - Last Name:MATHEW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, BC-CNS, BC ADM
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6269
Mailing Address - Fax:
Practice Address - Street 1:HWY 264, MPP 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200270015CNS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health