Provider Demographics
NPI:1841206901
Name:MATHISON-YOUNG, SUSAN MARY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:MATHISON-YOUNG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 72ND ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKE SHORE
Mailing Address - State:MN
Mailing Address - Zip Code:56468-6874
Mailing Address - Country:US
Mailing Address - Phone:218-568-7370
Mailing Address - Fax:
Practice Address - Street 1:11800 STATE AVE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-7308
Practice Address - Country:US
Practice Address - Phone:218-855-1115
Practice Address - Fax:218-855-1183
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology