Provider Demographics
NPI:1891011375
Name:CICMANEC, SARA LAUREN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LAUREN
Last Name:CICMANEC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2310
Mailing Address - Country:US
Mailing Address - Phone:385-282-2650
Mailing Address - Fax:
Practice Address - Street 1:389 S 900 E
Practice Address - Street 2:INTERMOUNTAIN SALT LAKE CLINIC
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:385-282-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8137257-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program