Provider Demographics
NPI:1801881131
Name:SASS, KIRSTEN INGEBORG (PA)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:INGEBORG
Last Name:SASS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:INGEBORG
Other - Last Name:WINKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:205 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICARE GROUP
TN1510139Medicaid
TNPA1262OtherPA LICENSE NUMBER
TN3380640OtherMEDICAID GROUP
TNQ54706OtherUPIN
TN3663927Medicare PIN