Provider Demographics
NPI:1104013127
Name:KIRYA, SARAH NAMUKONO (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:NAMUKONO
Last Name:KIRYA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 W BALL RD
Mailing Address - Street 2:4 B
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5500
Mailing Address - Country:US
Mailing Address - Phone:714-254-0224
Mailing Address - Fax:714-254-0234
Practice Address - Street 1:1720 W BALL RD
Practice Address - Street 2:4B
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5500
Practice Address - Country:US
Practice Address - Phone:174-254-0224
Practice Address - Fax:714-254-0234
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11713363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA11713Medicaid