Provider Demographics
NPI:1932642568
Name:SAGE ADULT AND GERIATRIC PRIMARY CARE LLC
Entity Type:Organization
Organization Name:SAGE ADULT AND GERIATRIC PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ES
Authorized Official - Suffix:
Authorized Official - Credentials:ANP/GNP
Authorized Official - Phone:541-296-4804
Mailing Address - Street 1:1015 WEBBER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3527
Mailing Address - Country:US
Mailing Address - Phone:541-296-4804
Mailing Address - Fax:541-296-3741
Practice Address - Street 1:1015 WEBBER ST STE 100
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3527
Practice Address - Country:US
Practice Address - Phone:541-296-4804
Practice Address - Fax:541-296-3741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150061NP363LA2200X
OR200150060NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty