Provider Demographics
NPI:1437108156
Name:AMUNDSEN, SUSAN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:200 MERCY DR STE 201
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7300
Practice Address - Country:US
Practice Address - Phone:563-584-3500
Practice Address - Fax:563-584-3520
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R40580Medicare UPIN
IA48770Medicare ID - Type Unspecified