Provider Demographics
NPI:1497713309
Name:BAEZ, SUSAN A (NPP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BAEZ
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 GREEN STREET
Mailing Address - Street 2:STE 2
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-339-3736
Mailing Address - Fax:845-339-6731
Practice Address - Street 1:105 MARY'S AVENUE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-338-2500
Practice Address - Fax:845-334-3172
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400833363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q30145Medicare UPIN
NY1033G1Medicare PIN