Basic Information
Provider Information | |||||||||
NPI: | 1164420261 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORRISON | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | LAURIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE | ||||||||
Address2: | DEPT. 358 | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986839324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607291462 | ||||||||
FaxNumber: | 3607293104 | ||||||||
Practice Location | |||||||||
Address1: | 1615 DELAWARE ST | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986322367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605013500 | ||||||||
FaxNumber: | 3605013555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 12/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | MD00042745 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | MD00042745 | WA | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 8377178 | 05 | WA |   | MEDICAID | P00392953 | 01 |   | RAILROAD MEDICARE | OTHER | 0217052 | 01 | WA | LABOR & IND | OTHER | 022615 | 05 | OR |   | MEDICAID | 8943479 | 01 | WA | CRIME VICTIMS | OTHER |