Provider Demographics
NPI:1659758134
Name:WALTKE, SARAH AGNES ECK (PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:AGNES ECK
Last Name:WALTKE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:AGNES ECK
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:607 S NEW BALLAS RD STE 3300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8219
Mailing Address - Country:US
Mailing Address - Phone:314-251-4400
Mailing Address - Fax:
Practice Address - Street 1:607 S NEW BALLAS RD STE 3300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8219
Practice Address - Country:US
Practice Address - Phone:314-251-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015012056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220024387Medicaid
MO2015012056OtherPA LICENSE