Provider Demographics
NPI:1710990148
Name:GAUGHAN, SUSAN ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELLEN
Last Name:GAUGHAN
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 1:87 LIAM LANE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02632-3354
Mailing Address - Country:US
Mailing Address - Phone:508-420-9726
Mailing Address - Fax:508-420-8204
Practice Address - Street 1:87 LIAM LANE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-3354
Practice Address - Country:US
Practice Address - Phone:508-420-9726
Practice Address - Fax:508-420-8204
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA94922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0378241Medicaid
MA0378241Medicaid
P33052Medicare UPIN