Provider Demographics
NPI:1629224282
Name:SASSE-WALLACE, MARGARET MARY (RDMS)
Entity Type:Individual
Prefix:MRS
First Name:MARGARET
Middle Name:MARY
Last Name:SASSE-WALLACE
Suffix:
Gender:F
Credentials:RDMS
Other - Prefix:MRS
Other - First Name:MEG
Other - Middle Name:MARY
Other - Last Name:SASSE-WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDMS
Mailing Address - Street 1:1942 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:NE
Mailing Address - Zip Code:69343-5400
Mailing Address - Country:US
Mailing Address - Phone:308-282-1599
Mailing Address - Fax:
Practice Address - Street 1:1942 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:NE
Practice Address - Zip Code:69343-5400
Practice Address - Country:US
Practice Address - Phone:308-282-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
267969247100000X, 2471M2300X
815962471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
NESASSE 8310Medicare PIN