Basic Information
Provider Information | |||||||||
NPI: | 1255397923 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NONDAHL | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PORTER | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4410 REGENT ST | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537054901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082339746 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4410 REGENT ST | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537054901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082339746 | ||||||||
FaxNumber: | 6082330026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2006 | ||||||||
LastUpdateDate: | 04/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 24853-020 | WI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 30615600 | 05 | WI |   | MEDICAID |