MEDICARE: SUSAN NEWBURN-MEDEL RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	10160	AK

General Provider Information

NPI Number	:	1104219666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN NEWBURN-MEDEL RN

Provider Business Mailing Address
First Line	:	3054 FIFTH AVE
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3054 FIFTH AVE
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5773
Country	:	US
Telephone Number	:	907-225-4350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2015
Last Update Date	:	03/09/2015

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