Provider Demographics
NPI:1720433899
Name:HAASE, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:HAASE
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 1:3905 SE 54TH AVE
Mailing Address - Street 2:#1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3982
Mailing Address - Country:US
Mailing Address - Phone:971-533-2521
Mailing Address - Fax:
Practice Address - Street 1:333 S STATE ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3932
Practice Address - Country:US
Practice Address - Phone:971-533-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21020171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor