Provider Demographics
NPI:1689298085
Name:WILSON, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 E MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2123
Mailing Address - Country:US
Mailing Address - Phone:801-734-0421
Mailing Address - Fax:
Practice Address - Street 1:7777 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-5518
Practice Address - Country:US
Practice Address - Phone:801-966-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8546685-3102163WG0000X
UT8546685-4405363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner