Provider Demographics
NPI:1912120270
Name:WILLSON-GOUCHER, SUSAN CAROL (RN, NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CAROL
Last Name:WILLSON-GOUCHER
Suffix:
Gender:F
Credentials:RN, NP
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Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:YACC 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-2080
Practice Address - Fax:617-414-2090
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MARN141147363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087703AMedicaid
MA001988601Medicare PIN