Provider Demographics
NPI:1437146479
Name:ANDERSON, SUSAN FAITH (NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:FAITH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 NORTH GRAND AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2760
Mailing Address - Country:US
Mailing Address - Phone:719-543-4000
Mailing Address - Fax:719-543-1041
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2760
Practice Address - Country:US
Practice Address - Phone:719-543-4000
Practice Address - Fax:719-543-1041
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93826575Medicaid