Provider Demographics
NPI:1124086707
Name:BACH, SUSAN E (FNP-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BACH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 MAIN ST
Mailing Address - Street 2:HEALTH SERIVES MICHAEL HALL
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-3001
Mailing Address - Country:US
Mailing Address - Phone:716-829-3316
Mailing Address - Fax:716-829-2564
Practice Address - Street 1:3435 MAIN ST
Practice Address - Street 2:HEALTH SERVICES MICHAEL HALL
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-3001
Practice Address - Country:US
Practice Address - Phone:716-829-3316
Practice Address - Fax:716-829-2564
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336098363LF0000X
NYF420616363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355266Medicaid
9513196OtherIHA LEGACY #
NYP00246624OtherMEDICARE RAILROAD LEGACY#
NY00355266Medicaid
NYDD3790Medicare ID - Type Unspecified