Provider Demographics
NPI:1508818154
Name:WILSON, SUSAN J (NNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32285 S KROPF RD
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-8563
Mailing Address - Country:US
Mailing Address - Phone:503-651-5262
Mailing Address - Fax:
Practice Address - Street 1:32285 S KROPF RD
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-8563
Practice Address - Country:US
Practice Address - Phone:503-651-5252
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR078041542N9 NNP363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal