Provider Demographics
NPI:1629056429
Name:MORAN, SUSAN L (NNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MORAN
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 1:4747 ARAPAHOE AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1133
Mailing Address - Country:US
Mailing Address - Phone:720-854-7152
Mailing Address - Fax:720-854-7114
Practice Address - Street 1:345 MAXWELL AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3972
Practice Address - Country:US
Practice Address - Phone:303-544-5777
Practice Address - Fax:303-544-5775
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3559363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34906746Medicaid
CO537428Medicare ID - Type Unspecified
CO34906746Medicaid
COQ20436Medicare UPIN