Healthcare Provider Details

I. General information

NPI: 1205835014
Provider Name (Legal Business Name): SUSAN K BUSSERT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E 2ND ST
GRANDVIEW WA
98930-1342
US

IV. Provider business mailing address

222 E 2ND ST
GRANDVIEW WA
98930-1342
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-3500
  • Fax: 509-882-2392
Mailing address:
  • Phone: 509-882-3500
  • Fax: 509-882-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: