Provider Demographics
NPI:1679037071
Name:VANDERGOOT, SARAH SOROOSH (FNP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:SOROOSH
Last Name:VANDERGOOT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:19485 OLD JETTON RD STE 100
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6583
Practice Address - Country:US
Practice Address - Phone:704-384-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011537363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner