Provider Demographics
NPI:1790784452
Name:EMERSON, MARY SUSAN (APRN, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUSAN
Last Name:EMERSON
Suffix:
Gender:F
Credentials:APRN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 TUMBLE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-7869
Mailing Address - Country:US
Mailing Address - Phone:918-606-0505
Mailing Address - Fax:
Practice Address - Street 1:2616 TUMBLE BROOK DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-7869
Practice Address - Country:US
Practice Address - Phone:918-606-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063436363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425324506Medicaid
MOS53458Medicare UPIN
MO425324506Medicaid