Provider Demographics
NPI:1790921732
Name:DJAVEDAN, SUSAN QUEEN I
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:QUEEN
Last Name:DJAVEDAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 UPTON AVE NO.
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412
Mailing Address - Country:US
Mailing Address - Phone:702-506-2305
Mailing Address - Fax:
Practice Address - Street 1:4100 UPTON AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1522
Practice Address - Country:US
Practice Address - Phone:702-506-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL045270-0163W00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine