Basic Information
| Provider Information | |||||||||
| NPI: | 1962711796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIEBLE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MERCEDES | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5777 E MAYO BLVD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850544502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803421387 | ||||||||
| FaxNumber: | 4803421388 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 E 19TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207544800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 4722 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 4868 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4868 | 01 | CO | COLORADO PA LICENSE | OTHER |