Provider Demographics
NPI:1821024480
Name:DOUGHERTY, SARA (NP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 S BINGHAM JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4804
Mailing Address - Country:US
Mailing Address - Phone:801-442-5502
Mailing Address - Fax:
Practice Address - Street 1:7302 S BINGHAM JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4804
Practice Address - Country:US
Practice Address - Phone:801-442-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120828363L00000X
NVAPRN002108363LF0000X
UT10814308-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428623219Medicaid
OK100183120AMedicaid
MO173861OtherANTHEM
NV1821024480OtherSMA MEDICAID
500014122OtherRR MEDICARE
NVV112696OtherSMA MEDICARE
KS200000240AMedicaid
500014122OtherRR MEDICARE