Provider Demographics
NPI:1699779546
Name:GINGERICH, SUE ANN (CRNA)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:GINGERICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:ANN
Other - Last Name:ROETUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17893 224TH ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-8629
Mailing Address - Country:US
Mailing Address - Phone:563-927-6183
Mailing Address - Fax:563-927-6183
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD090526367500000X
IL209005003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5542936Medicaid
IA30980OtherWASHINGTON BC/BS IOWA
IA2542936Medicaid
IA30980OtherWASHINGTON BC/BS IOWA
IA5542936Medicaid
IAI7815Medicare ID - Type UnspecifiedWASHINGTON MEDICARE
IAI17282Medicare ID - Type UnspecifiedRMC MEDICARE