Provider Demographics
NPI:1174619787
Name:RIESEL, SUSAN JANE (WHPAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:RIESEL
Suffix:
Gender:F
Credentials:WHPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 NINTH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:770 10TH STREET
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521
Practice Address - Country:US
Practice Address - Phone:707-826-8610
Practice Address - Fax:707-826-8623
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA50880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant