Basic Information
| Provider Information | |||||||||
| NPI: | 1265518633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHASSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | APRN/CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 WEST 940 NORTH | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577930 | ||||||||
| FaxNumber: | 8013577014 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 WEST 940 NORTH | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577930 | ||||||||
| FaxNumber: | 8013577014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 219067-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 219067-4402 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 942854058788-D5889 | 05 | UT | MEDICAID |