Provider Demographics
NPI:1447410972
Name:FRIED, SUSAN ANN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:FRIED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-5100
Mailing Address - Fax:704-316-5101
Practice Address - Street 1:301 HAWTHORNE LN STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2467
Practice Address - Country:US
Practice Address - Phone:704-316-5100
Practice Address - Fax:704-316-5101
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00177000363AS0400X
NC0010-05406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447410972Medicaid
NCNCN861AMedicare PIN