Provider Demographics
NPI:1639620057
Name:ANDERSON, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3640 HIGH ST
Mailing Address - Street 2:SUITE 2-F
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3213
Mailing Address - Country:US
Mailing Address - Phone:757-483-3030
Mailing Address - Fax:757-484-7239
Practice Address - Street 1:3640 HIGH ST
Practice Address - Street 2:SUITE 2-F
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3213
Practice Address - Country:US
Practice Address - Phone:757-483-3030
Practice Address - Fax:757-484-7239
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1014Medicare PIN