Provider Demographics
NPI:1508865007
Name:JUMPING EAGLE, SARA JUANITA (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JUANITA
Last Name:JUMPING EAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NORTH RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538
Mailing Address - Country:US
Mailing Address - Phone:701-854-3831
Mailing Address - Fax:701-854-7399
Practice Address - Street 1:10 N. RIVER RD.
Practice Address - Street 2:FORT YATES IHS HOSPITAL/CLINIC
Practice Address - City:FT. YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:701-854-7399
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND110192080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15044Medicaid