Provider Demographics
NPI:1184271975
Name:BLODGETT, SARA BETH
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:BETH
Last Name:BLODGETT
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:833-476-0765
Practice Address - Street 1:576 KOKOPELLI BLVD UNIT D-E
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-6304
Practice Address - Country:US
Practice Address - Phone:970-858-2590
Practice Address - Fax:970-858-5036
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant