Provider Demographics
NPI:1508860289
Name:GILLIS, SARA N (CPNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:N
Last Name:GILLIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HIGHLAND AVE SE
Mailing Address - Street 2:STE 100
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2218
Mailing Address - Country:US
Mailing Address - Phone:540-344-9213
Mailing Address - Fax:540-345-7559
Practice Address - Street 1:21 HIGHLAND AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2218
Practice Address - Country:US
Practice Address - Phone:540-344-9213
Practice Address - Fax:540-345-7559
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001137848363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54088505612OtherJOHN DEERE
VA5657671OtherAETNA