Provider Demographics
NPI:1962487108
Name:MORGAN, SUSAN ANNE (CNM, FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNE
Last Name:MORGAN
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1775 THOMPSON RD.
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2125
Mailing Address - Country:US
Mailing Address - Phone:541-269-8538
Mailing Address - Fax:541-267-5083
Practice Address - Street 1:1775 THOMPSON RD.
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8538
Practice Address - Fax:541-267-5083
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250115NP363L00000X
OR077010025N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR076815Medicaid
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR03-15-2007OtherNBMC TERMINATION DATE
OR93-0635514OtherGROUP TAX ID FOR BILLING
OR93-0635514OtherGROUP TAX ID FOR BILLING
OR0000WFBTV-114075Medicare ID - Type UnspecifiedGROUP & INDIVIDUAL