Provider Demographics
NPI:1821099813
Name:ETHUN, SUSAN K (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:ETHUN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1049
Mailing Address - Country:US
Mailing Address - Phone:608-768-6255
Mailing Address - Fax:608-524-0842
Practice Address - Street 1:2000 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1049
Practice Address - Country:US
Practice Address - Phone:608-768-6255
Practice Address - Fax:608-524-0842
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2407-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41183800Medicaid
Q23598Medicare UPIN