Provider Demographics
NPI:1073786711
Name:PETERSEN, SARAH CONNORS (MD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:CONNORS
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510708
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84151-0708
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:5126 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5994
Practice Address - Country:US
Practice Address - Phone:801-213-4500
Practice Address - Fax:801-213-4509
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006023670208000000X
UT7536208-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068888Medicare PIN