Provider Demographics
NPI:1710480843
Name:WILLIAMS, SAGE ALEXANDER
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:ALEXANDER
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6384 COVENANT CREST CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1300
Mailing Address - Country:US
Mailing Address - Phone:702-476-5058
Mailing Address - Fax:702-476-5125
Practice Address - Street 1:9745 GRAND TETON DR UNIT 89166
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166-1017
Practice Address - Country:US
Practice Address - Phone:702-517-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion