Provider Demographics
NPI:1679514830
Name:WALLS-BORTMAN, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WALLS-BORTMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 N. WYATT DRIVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-545-0608
Mailing Address - Fax:520-795-0354
Practice Address - Street 1:174 S CORONADO DR STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6356
Practice Address - Country:US
Practice Address - Phone:520-545-0676
Practice Address - Fax:520-547-2993
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ043027163W00000X
AZAP1736363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ817223Medicaid
AZ817223Medicaid
Q02948Medicare UPIN