Provider Demographics
NPI:1194031419
Name:NULL, SARAH (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:NULL
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 1:2560 CENTRAL PARK AVE STE 195
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1566
Mailing Address - Country:US
Mailing Address - Phone:972-420-1475
Mailing Address - Fax:972-539-8000
Practice Address - Street 1:2560 CENTRAL PARK AVE STE 195
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1566
Practice Address - Country:US
Practice Address - Phone:972-420-1475
Practice Address - Fax:972-539-8000
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMORARY207Q00000X
TXPA06852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA06852OtherLICENSE
TXPA06852OtherLICENSE
TXTXB145916Medicare PIN
TXTXB145924Medicare PIN