Provider Demographics
NPI:1659415842
Name:PAIR, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PAIR
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 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2302
Practice Address - Country:US
Practice Address - Phone:515-263-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089666367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2400122Medicaid
IA0400122Medicaid
IA58124OtherWELLMARK
IA0400122Medicaid