Provider Demographics
NPI:1790428712
Name:ANDERSON, SUSAN (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:1397 GALLERIA DR STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6660
Practice Address - Country:US
Practice Address - Phone:702-436-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV813670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1790428712Medicaid
NV813670OtherSTATE LICENSE