Provider Demographics
NPI:1518072206
Name:FERGUSON, SARAH (NP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:FERGUSON
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 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3188
Mailing Address - Country:US
Mailing Address - Phone:815-337-1871
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-356-5382
Practice Address - Fax:815-356-2385
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004232363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL962341Medicare PIN