Provider Demographics
NPI:1396799524
Name:IVANKOVICH, SUSAN E (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:IVANKOVICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:AHLQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MT
Mailing Address - Zip Code:59019-0959
Mailing Address - Country:US
Mailing Address - Phone:406-322-1000
Mailing Address - Fax:406-322-5207
Practice Address - Street 1:710 11TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MT
Practice Address - Zip Code:59019-7215
Practice Address - Country:US
Practice Address - Phone:406-322-1000
Practice Address - Fax:406-322-5207
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT35802363AM0700X
MN24323207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
24323OtherNDBCBS
54A23AHOtherMNBCBS
MTM011005451Medicare Oscar/Certification
R02368Medicare UPIN