Provider Demographics
NPI:1538139704
Name:WISEMAN, SUSAN HEADY (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:HEADY
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MISSION HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1406
Mailing Address - Country:US
Mailing Address - Phone:970-556-5720
Mailing Address - Fax:
Practice Address - Street 1:6 MISSION HILLS CIR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1406
Practice Address - Country:US
Practice Address - Phone:970-556-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO162882367500000X
ARR84434367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO803628Medicare ID - Type Unspecified