Provider Demographics
NPI:1497206510
Name:MIRTS, SUZANNE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:MIRTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31ST MEDICAL GROUP/SGST
Mailing Address - Street 2:UNIT 6180
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09604-6180
Mailing Address - Country:US
Mailing Address - Phone:314-632-5560
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP
Practice Address - Street 2:UNIT 6180
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604-6180
Practice Address - Country:US
Practice Address - Phone:314-632-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN0172411163W00000X
COAPN.0993284-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse