Provider Demographics
NPI:1295726602
Name:MEHTA, SUSAN MISKOVICH (FNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MISKOVICH
Last Name:MEHTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 LEPHILLIP COURT NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2900
Mailing Address - Country:US
Mailing Address - Phone:704-403-7770
Mailing Address - Fax:704-403-7779
Practice Address - Street 1:219 LEPHILLIP COURT NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2900
Practice Address - Country:US
Practice Address - Phone:704-403-7770
Practice Address - Fax:704-403-7779
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC076981163WP2201X
NC67386363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232009OtherMEDICARE PTAN, GROUP CMCNE
NC232009OtherMEDICARE PTAN, GROUP CMCNE
NCS01017Medicare UPIN
NC2593883AMedicare PIN
NC2593883Medicare PIN