Provider Demographics
NPI:1467647115
Name:MIX, SUSAN M (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MIX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 GOLF VIEW DRIVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-618-4400
Mailing Address - Fax:541-618-4406
Practice Address - Street 1:760 GOLF VIEW DRIVE
Practice Address - Street 2:SUITE #200
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-618-4400
Practice Address - Fax:541-618-4406
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750116NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid
R140955Medicare PIN