Provider Demographics
NPI:1912951674
Name:MOONEY, SUSAN J (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MOONEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7788 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4342
Mailing Address - Country:US
Mailing Address - Phone:505-999-1600
Mailing Address - Fax:505-999-1654
Practice Address - Street 1:7788 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4342
Practice Address - Country:US
Practice Address - Phone:505-999-1600
Practice Address - Fax:505-999-1654
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01278367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95259759Medicaid
NM95259759Medicaid
TX109920204Medicaid
TX8856UAOtherBCBS
TXTXB118600Medicare PIN
TX8A7439Medicare ID - Type UnspecifiedCOLLIN COUNTY
TN8A7436Medicare ID - Type UnspecifiedDALLAS COUNTY