Provider Demographics
NPI:1932147212
Name:SANDERS, SUSAN KOVAC (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KOVAC
Last Name:SANDERS
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 1:6110 SONG BREEZE TRCE
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1470
Mailing Address - Country:US
Mailing Address - Phone:404-754-6020
Mailing Address - Fax:770-379-4501
Practice Address - Street 1:3602 KYOTO GARDENS DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-2713
Practice Address - Country:US
Practice Address - Phone:561-799-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9168731367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
G2875OtherBCBS
FL303992700Medicaid
G2875DMedicare ID - Type Unspecified