Provider Demographics
NPI:1265089205
Name:SUPRISE, SARAH (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SUPRISE
Suffix:
Gender:F
Credentials:MMS, PA-C
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 912
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-0912
Mailing Address - Country:US
Mailing Address - Phone:970-625-6555
Mailing Address - Fax:
Practice Address - Street 1:501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-8510
Practice Address - Country:US
Practice Address - Phone:269-207-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006292363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program