Provider Demographics
NPI:1659758134
Name:TIPTON, SARAH AGNES ECK (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:AGNES ECK
Last Name:TIPTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 E RIVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8807
Mailing Address - Country:US
Mailing Address - Phone:417-820-5610
Mailing Address - Fax:
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8807
Practice Address - Country:US
Practice Address - Phone:417-820-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015012056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220024387Medicaid
MO2015012056OtherPA LICENSE