Provider Demographics
NPI:1992919484
Name:BALTZ, SUSAN A (FNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:BALTZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015
Mailing Address - Country:US
Mailing Address - Phone:806-206-1494
Mailing Address - Fax:806-731-1516
Practice Address - Street 1:5211 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4120
Practice Address - Country:US
Practice Address - Phone:806-731-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP107029363L00000X
TX251159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092280501Medicaid
TX041445004Medicaid
TX279068ZHVZMedicare PIN
TXS67920Medicare UPIN
TX041445004Medicaid