Provider Demographics
NPI:1619013869
Name:SMITH, SUSAN J (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9640 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2217
Mailing Address - Country:US
Mailing Address - Phone:505-294-4167
Mailing Address - Fax:
Practice Address - Street 1:9640 MENAUL BLVD NE
Practice Address - Street 2:CVS MINUTE CLINIC
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2217
Practice Address - Country:US
Practice Address - Phone:505-294-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR30405207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q2493Medicaid
S47905Medicare UPIN
$$$$$$$$$Medicare PIN