Basic Information
| Provider Information | |||||||||
| NPI: | 1336360254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTT HEASLEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206692500 | ||||||||
| FaxNumber: | 3165406193 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHENEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670258844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202596221 | ||||||||
| FaxNumber: | 3165406193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2011020340 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 6554 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 05-45046 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 431560263 | 01 | MO | TRICARE | OTHER | 1336360254 | 05 | MO | MEDICAID | P00985977 | 01 | MO | RR MCR | OTHER |