Provider Demographics
NPI:1962653089
Name:LIDDELL, SARAH NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SARAH
Middle Name:NICOLE
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:NICOLE
Other - Last Name:BAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:501 GOPHER DR
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-4513
Mailing Address - Country:US
Mailing Address - Phone:608-372-2181
Mailing Address - Fax:
Practice Address - Street 1:501 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2346-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant