Provider Demographics
NPI:1790823078
Name:JURGENS, SARA BL (PAC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:BL
Last Name:JURGENS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10240 PARK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5425
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3220363AS0400X
IL085002920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0739010001OtherMEDICARE NSC
IL0739010005OtherMEDICARE NSC
IL0739010008OtherMEDICARE NSC
ILCD4744OtherRAILROAD MEDICARE GROUP #
IL208887OtherMEDICARE LOCALITY 15
IL0739010006OtherMEDICARE NSC
IL208592OtherMEDICARE LOCALITY 99
ILP00408910OtherRAILROAD MEDICARE
CO025480OtherKAISER COMMERCIAL NUMBER
IL085002920OtherST. OF IL LICENSE
CO93159579Medicaid
ILP00408910OtherRAILROAD MEDICARE
IL208592OtherMEDICARE LOCALITY 99
ILCD4744OtherRAILROAD MEDICARE GROUP #
CO93159579Medicaid
IL085002920OtherST. OF IL LICENSE