Provider Demographics
NPI:1972506202
Name:BERG, SUSAN E (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BERG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1257
Mailing Address - Country:US
Mailing Address - Phone:541-471-3455
Mailing Address - Fax:541-471-1439
Practice Address - Street 1:25647 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9332
Practice Address - Country:US
Practice Address - Phone:541-592-4111
Practice Address - Fax:541-592-3916
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006914364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8852116Medicare ID - Type Unspecified
WAQ39742Medicare UPIN
WA9644501Medicaid