Provider Demographics
NPI:1609155381
Name:HALLETT, SARAH BACKUS (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BACKUS
Last Name:HALLETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:RUTH
Other - Last Name:BACKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1555 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7870
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7870
Practice Address - Fax:585-723-7871
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015064363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04059821Medicaid
NYJ400054429/GRPBA0017Medicare PIN