Provider Demographics
NPI:1417929704
Name:SOUTHARD, SARAH (NP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PAR DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2254
Practice Address - Country:US
Practice Address - Phone:540-985-9835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001-078793163W00000X
VA0024078793363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007781105Medicaid
VA007781105Medicaid