Provider Demographics
NPI:1255847844
Name:UNGERLEIDER, SAGE R (CNM)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:R
Last Name:UNGERLEIDER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 BOLTON RD
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:MA
Mailing Address - Zip Code:01451-1846
Mailing Address - Country:US
Mailing Address - Phone:617-501-6970
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2273225367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife