Basic Information
| Provider Information | |||||||||
| NPI: | 1245540137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 SW WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760285330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174471208 | ||||||||
| FaxNumber: | 8174471106 | ||||||||
| Practice Location | |||||||||
| Address1: | 434 SW WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760285330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174471208 | ||||||||
| FaxNumber: | 8174471106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2010 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 628756 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP115646 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.