Basic Information
| Provider Information | |||||||||
| NPI: | 1578562401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1850 | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975231850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415924111 | ||||||||
| FaxNumber: | 5415923916 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 CAVES HWY | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975239604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415924111 | ||||||||
| FaxNumber: | 5415923916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363A00000X | PA00515 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 127725 | 05 | OR | MEDICAID |