Provider Demographics
NPI:1336237593
Name:SUTHERLAND, WILLIAM MARK (MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-1422
Mailing Address - Country:US
Mailing Address - Phone:570-675-2784
Mailing Address - Fax:
Practice Address - Street 1:700 QUINCY AVE
Practice Address - Street 2:MOSES TAYLOR HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1724
Practice Address - Country:US
Practice Address - Phone:570-340-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP004895M363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR108754Medicare UPIN
PAP24788Medicare UPIN
PAP00471076Medicare UPIN
PA083950Medicare UPIN
ORC92485Medicare UPIN