Provider Demographics
NPI:1861457194
Name:BAUER, SUSAN J (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:BAUER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 EISENHOWER AVE
Mailing Address - Street 2:GREAT BEND CHILDREN'S CLINIC
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3213
Mailing Address - Country:US
Mailing Address - Phone:620-792-5848
Mailing Address - Fax:
Practice Address - Street 1:1021 EISENHOWER AVE
Practice Address - Street 2:GREAT BEND CHILDREN'S CLINIC
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3213
Practice Address - Country:US
Practice Address - Phone:620-792-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44343363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS013253OtherBLUE CROSS INDIV PROVIDER
KS200269380AMedicaid