Provider Demographics
NPI:1609505874
Name:RADECKI, SARAH ELISABETH (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELISABETH
Last Name:RADECKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16523 WILD HORSE CREEK RD APT 1216
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 THE LEGENDS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-3825
Practice Address - Country:US
Practice Address - Phone:636-549-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-05
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022042681363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program