Provider Demographics
NPI:1265739742
Name:ALBRIGHT, SUSAN LARA (ANP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LARA
Last Name:ALBRIGHT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD OFC
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-8176
Mailing Address - Fax:
Practice Address - Street 1:537 UNION AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-507-2170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-18
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12204-NP363LF0000X
OR201501648NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500686240Medicaid
ORR181068Medicare UPIN