Provider Demographics
NPI:1871675892
Name:QUISTGAARD, SUSANNE (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:QUISTGAARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7315 212TH ST SW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7610
Mailing Address - Country:US
Mailing Address - Phone:425-775-9474
Mailing Address - Fax:415-670-3554
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:SUITE 101
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-775-9474
Practice Address - Fax:415-670-3554
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00033171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8192999Medicaid
WAGAB20779Medicare PIN
WA8192999Medicaid