Provider Demographics
NPI:1699852699
Name:GABA, SUSAN I (APRN-BC, MSN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:I
Last Name:GABA
Suffix:
Gender:F
Credentials:APRN-BC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:480-352-1439
Mailing Address - Fax:
Practice Address - Street 1:3003 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2902
Practice Address - Country:US
Practice Address - Phone:480-352-1439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103763Medicaid
AZSIG44Medicare UPIN
AZZ103769Medicare ID - Type Unspecified
AZ103763Medicaid