Provider Demographics
NPI:1780751479
Name:DUNGAN, SUSAN M (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:DUNGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 GLEN COVE DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8414
Mailing Address - Country:US
Mailing Address - Phone:318-965-4341
Mailing Address - Fax:
Practice Address - Street 1:1811 E BERT KOUNS
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-222-3695
Practice Address - Fax:318-424-0717
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN089268 AP04806363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1409537Medicaid
LA1409537Medicaid
LA3A023D252Medicare PIN