Provider Demographics
NPI:1942890041
Name:ELLERBE, SARA WILSON (PA)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:WILSON
Last Name:ELLERBE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1872
Mailing Address - Country:US
Mailing Address - Phone:510-402-4005
Mailing Address - Fax:
Practice Address - Street 1:1670 ST VINCENTS WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8447
Practice Address - Country:US
Practice Address - Phone:510-402-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant