Provider Demographics
NPI:1124377247
Name:STOUT, SARAH A (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:A
Last Name:STOUT
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:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-234-4468
Mailing Address - Fax:919-234-4478
Practice Address - Street 1:160 MACGREGOR PINES DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-234-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124377247Medicaid