Provider Demographics
NPI:1609521335
Name:MATHEW, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MATHEW
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 1:6428 ROSALIE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1783
Mailing Address - Country:US
Mailing Address - Phone:301-910-4617
Mailing Address - Fax:
Practice Address - Street 1:3411 OLANDWOOD CT STE 105
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1488
Practice Address - Country:US
Practice Address - Phone:301-910-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR183817363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty