Provider Demographics
NPI:1609836360
Name:CHOBANOV, SUSAN KAY
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:CHOBANOV
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 1:1897 MCKINLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-8453
Mailing Address - Country:US
Mailing Address - Phone:715-477-2198
Mailing Address - Fax:
Practice Address - Street 1:1897 MCKINLEY BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-8453
Practice Address - Country:US
Practice Address - Phone:715-477-2198
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV38324400Medicaid