Provider Demographics
NPI:1750375226
Name:SCHMIDT, SUSAN DISSELKOEN (NP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DISSELKOEN
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DISSELKOEN
Other - Last Name:STEPHANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S PARKSIDE DR STE 215
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3131
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO025437OtherKAISER COMMERCIAL NUMBER
CO01037765Medicaid
CO370931YK5YMedicare PIN