Provider Demographics
NPI:1063417954
Name:ROBERTS, SUSAN K (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1842 SUGARLAND DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5719
Mailing Address - Country:US
Mailing Address - Phone:307-673-4960
Mailing Address - Fax:307-673-4951
Practice Address - Street 1:1842 SUGARLAND DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5719
Practice Address - Country:US
Practice Address - Phone:307-673-4960
Practice Address - Fax:307-673-4951
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2011-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WY6397A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW24224OtherMEDICARE PTAN
WY452516681OtherBUSINESSTAX ID (EIN)
WYW24224OtherMEDICARE PTAN