Provider Demographics
NPI:1851550875
Name:MATHSON, SARA LYNNE (IDC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LYNNE
Last Name:MATHSON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 475
Mailing Address - Street 2:BOX 1444
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 475
Practice Address - Street 2:BOX 1444
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-9998
Practice Address - Country:US
Practice Address - Phone:706-478-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman