Provider Demographics
NPI:1932169059
Name:VAWTER, SUSAN PATRICIA (MN, CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:PATRICIA
Last Name:VAWTER
Suffix:
Gender:F
Credentials:MN, CNM
Other - Prefix:
Other - First Name:TRISH
Other - Middle Name:
Other - Last Name:VAWTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST
Practice Address - Street 2:SUITE 114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1763
Practice Address - Country:US
Practice Address - Phone:503-215-6262
Practice Address - Fax:503-234-5437
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350066NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298493Medicaid
ORR175085Medicare PIN
Q39351Medicare UPIN
OR298493Medicaid