Provider Demographics
NPI:1831193184
Name:ROSENBERG, SUSAN (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MIRIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667-1413
Mailing Address - Country:US
Mailing Address - Phone:508-349-3131
Mailing Address - Fax:508-349-1311
Practice Address - Street 1:3130 STATE HWY RTE 6
Practice Address - Street 2:
Practice Address - City:WELLFLEET
Practice Address - State:MA
Practice Address - Zip Code:02667-7402
Practice Address - Country:US
Practice Address - Phone:508-349-3131
Practice Address - Fax:508-349-1311
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN266415OtherSTATE LICENSE
MAR89982Medicare UPIN