Provider Demographics
NPI:1922671353
Name:ODAK, SUSAN GERO
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GERO
Last Name:ODAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 SHAVANO LN
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-6706
Mailing Address - Country:US
Mailing Address - Phone:763-742-3252
Mailing Address - Fax:
Practice Address - Street 1:7726 SHAVANO LN
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-6706
Practice Address - Country:US
Practice Address - Phone:763-742-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF07211228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily