Provider Demographics
NPI:1205906823
Name:FETTER, SUZANNE LARSON (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LARSON
Last Name:FETTER
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 1:8 PROSPECT ST
Mailing Address - Street 2:NICU
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3925
Mailing Address - Country:US
Mailing Address - Phone:603-577-2565
Mailing Address - Fax:603-577-2084
Practice Address - Street 1:8 PROSPECT ST
Practice Address - Street 2:NICU
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3925
Practice Address - Country:US
Practice Address - Phone:603-577-2565
Practice Address - Fax:603-577-2084
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10820208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201193Medicaid
NHRE6001Medicare ID - Type Unspecified
NH30201193Medicaid