Provider Demographics
NPI:1356313811
Name:MATTHEW, SUSAN A (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:MATTHEW
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7236 JORDAN DRIVE SUITE 101
Mailing Address - Street 2:PO BOX 6540
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6540
Mailing Address - Country:US
Mailing Address - Phone:605-341-5565
Mailing Address - Fax:605-341-5595
Practice Address - Street 1:7236 JORDAN DRIVE SUITE 101
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-341-5565
Practice Address - Fax:605-341-5595
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0284363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0040887OtherWELLMARK BCBS NUMBER
WY311949OtherWY BCBS NUMBER
SD6824580Medicaid
SD0040887OtherWELLMARK BCBS NUMBER
SD40887Medicare ID - Type UnspecifiedSD MEDICARE NUMBER
SDP00110317Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
WY9487Medicare ID - Type UnspecifiedWY MEDICARE NUMBER