Provider Demographics
NPI:1811354509
Name:SIPPERLY, SAVANNAH (PA)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:SIPPERLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 PONDHAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8122
Mailing Address - Country:US
Mailing Address - Phone:704-682-1805
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010 06295OtherSTATE OF NORTH CAROLINA