Provider Demographics
NPI:1952342925
Name:ROSS, SUSANNE (NP)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:
Other - Last Name:BOATMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1910 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-2899
Mailing Address - Country:US
Mailing Address - Phone:707-443-9747
Mailing Address - Fax:707-269-1332
Practice Address - Street 1:1910 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2870
Practice Address - Country:US
Practice Address - Phone:925-381-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10116363L00000X
CANP10116363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ06571Medicare UPIN