Basic Information
| Provider Information | |||||||||
| NPI: | 1275519134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURLBUT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 HUCKLEBERRY AVE | ||||||||
| Address2: | |||||||||
| City: | OMRO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549631851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206857280 | ||||||||
| FaxNumber: | 9203035630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HUCKLEBERRY AVE | ||||||||
| Address2: | |||||||||
| City: | OMRO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549631851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206857280 | ||||||||
| FaxNumber: | 9203035630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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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 | 363L00000X | 1425 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43994400 | 05 | WI | MEDICAID |