Provider Demographics
NPI:1821068412
Name:LINEHAN, SUSAN J (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:LINEHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 W GENESEE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2162
Mailing Address - Country:US
Mailing Address - Phone:315-487-8109
Mailing Address - Fax:315-487-5680
Practice Address - Street 1:5415 W GENESEE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2162
Practice Address - Country:US
Practice Address - Phone:315-487-8109
Practice Address - Fax:315-487-5680
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF000479363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01791111Medicaid
NYS27222Medicare UPIN
NY01791111Medicaid