Provider Demographics
NPI:1669833018
Name:MATHEWS, SARA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 D L INGRAM AVE W
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:575-784-6329
Practice Address - Street 1:208 D L INGRAM AVE W
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5103
Practice Address - Country:US
Practice Address - Phone:575-265-2411
Practice Address - Fax:575-784-6329
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE30237171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program