Provider Demographics
NPI:1063464105
Name:PICKETT, SARA J (PA-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S. DOBSON RD. #223
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286
Mailing Address - Country:US
Mailing Address - Phone:480-821-8888
Mailing Address - Fax:480-821-0888
Practice Address - Street 1:1100 S. DOBSON RD #223
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286
Practice Address - Country:US
Practice Address - Phone:480-821-8888
Practice Address - Fax:480-821-0888
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5103363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC808519Medicare PIN
C808519Medicare PIN