Provider Demographics
NPI:1417949884
Name:SMITH, SUSAN R (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2408
Mailing Address - Country:US
Mailing Address - Phone:704-375-0100
Mailing Address - Fax:704-887-6450
Practice Address - Street 1:1420 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2408
Practice Address - Country:US
Practice Address - Phone:704-375-0100
Practice Address - Fax:704-887-6450
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79105363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00210985OtherRR MEDICARE
NC2594929CMedicare PIN
S45201Medicare UPIN