Provider Demographics
NPI:1407226038
Name:WIENS, SARA (PA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WIENS
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 1:31922 VIA COYOTE
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-4109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31922 VIA COYOTE
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-4109
Practice Address - Country:US
Practice Address - Phone:323-640-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant