Healthcare Provider Details

I. General information

NPI: 1043383508
Provider Name (Legal Business Name): SUSAN FLANIGAN BATES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCMWTC BLDG 3005 HC 83 BOX 1
BRIDGEPORT CA
93517
US

IV. Provider business mailing address

663 SADDLEBACK DR
PAGOSA SPRINGS CO
81147-7732
US

V. Phone/Fax

Practice location:
  • Phone: 760-932-1616
  • Fax:
Mailing address:
  • Phone: 970-264-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number658016
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: