Provider Demographics
NPI:1417527862
Name:FAIRAQ, SARA JAMAL (APNP)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:JAMAL
Last Name:FAIRAQ
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11011 W NORTH AVE APT 446
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2274
Mailing Address - Country:US
Mailing Address - Phone:414-949-0082
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-0506
Practice Address - Fax:414-955-6211
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1060033363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care