Provider Demographics
NPI:1073564704
Name:MACOMBER, SARAH A (CRNA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:A
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:A
Other - Last Name:TILLOTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4045
Practice Address - Fax:682-885-7497
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164208403Medicaid
TX8G0552Medicare PIN
TX00N47FMedicare PIN
TX164208403Medicaid