Provider Demographics
NPI:1073523726
Name:POPOVICH, SARA T (PA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:T
Last Name:POPOVICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:1287 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5545
Practice Address - Country:US
Practice Address - Phone:941-244-5706
Practice Address - Fax:941-800-4342
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002115363AS0400X
FLPA9106884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102562600Medicaid
FLLB278OtherMEDICARE
FLY0JT6OtherBCBS