Provider Demographics
NPI:1740918754
Name:EBSEN, SARA (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:EBSEN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:GLOMSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:414-805-6864
Practice Address - Street 1:1284 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-560-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13424-033363L00000X
WI232463363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740918754Medicaid