Provider Demographics
NPI:1255836664
Name:PISTILLI, SARA MARIE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:PISTILLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-4012
Mailing Address - Country:US
Mailing Address - Phone:763-639-8748
Mailing Address - Fax:
Practice Address - Street 1:2401 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1010
Practice Address - Country:US
Practice Address - Phone:763-639-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35480390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program