Provider Demographics
NPI:1720053879
Name:BOLICK, SARAH B (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:B
Last Name:BOLICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:E
Other - Last Name:BRASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:270 CHASTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3012
Mailing Address - Country:US
Mailing Address - Phone:770-421-8005
Mailing Address - Fax:770-424-5662
Practice Address - Street 1:270 CHASTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3012
Practice Address - Country:US
Practice Address - Phone:770-421-8005
Practice Address - Fax:770-424-5662
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA842696858DMedicaid
GA842696858GMedicaid
GA842696858EMedicaid
GA842696858CMedicaid
GA842696858FMedicaid
GA842696858EMedicaid
GA842696858GMedicaid