Provider Demographics
NPI:1376138859
Name:CARBAJAL, SUSAN M (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-809-5419
Practice Address - Fax:228-809-5076
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2022-05-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS904490363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00072750Medicaid