Provider Demographics
NPI:1649268517
Name:SMALL, SUSAN (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2203
Mailing Address - Fax:319-356-4005
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2203
Practice Address - Fax:319-356-4005
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS049024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA43362OtherWELLMARK BCBS
IA0423145Medicaid
IAI0923265Medicare PIN
IAI4827Medicare PIN
P44219Medicare UPIN
IA0423145Medicaid