Provider Demographics
NPI:1215126958
Name:OVERCASH, SUSAN D (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:OVERCASH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-460-3100
Mailing Address - Fax:260-460-3130
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-460-3100
Practice Address - Fax:260-460-3130
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001699A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5506830001Medicare NSC
IN5506830003Medicare NSC
IN668120WMedicare PIN