Provider Demographics
NPI:1265547335
Name:ERTAC, SUSANA (RN, NP)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:ERTAC
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2431 PORT WHITBY PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5435
Mailing Address - Country:US
Mailing Address - Phone:949-706-2958
Mailing Address - Fax:714-744-4167
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:STE 501
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4213
Practice Address - Country:US
Practice Address - Phone:714-771-7994
Practice Address - Fax:714-744-4167
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA9601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA537812OtherREGISTERED NURSE LIC
CA9601OtherNURSE PRACTITIONER LIC