Provider Demographics
NPI:1295576635
Name:WARREN, SUSAN (RADT 1)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:RADT 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 NW BINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1214
Mailing Address - Country:US
Mailing Address - Phone:580-492-3240
Mailing Address - Fax:
Practice Address - Street 1:584 NW BINGO RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1214
Practice Address - Country:US
Practice Address - Phone:580-492-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist