Provider Demographics
NPI:1801021472
Name:MACHUCA, SUSAN BANCROFT (LMP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BANCROFT
Last Name:MACHUCA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 SE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-7306
Mailing Address - Country:US
Mailing Address - Phone:206-436-9883
Mailing Address - Fax:
Practice Address - Street 1:1220 116TH AVE NE STE 203
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3826
Practice Address - Country:US
Practice Address - Phone:206-436-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60081937174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist