Provider Demographics
NPI:1861654014
Name:HOSTETLER, SARAH GRIM (MD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:GRIM
Last Name:HOSTETLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:GRIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 PINE RIDGE BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4124
Mailing Address - Country:US
Mailing Address - Phone:715-847-2626
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD STE 305
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4124
Practice Address - Country:US
Practice Address - Phone:715-847-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI57456-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program