Provider Demographics
NPI:1952524621
Name:SAPP, JUANITA (MD)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:SAPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 LANE 13
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-8710
Mailing Address - Country:US
Mailing Address - Phone:307-764-4107
Mailing Address - Fax:307-764-1892
Practice Address - Street 1:128 N BENT ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2712
Practice Address - Country:US
Practice Address - Phone:307-765-4107
Practice Address - Fax:307-764-1892
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14829207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYD44458Medicare UPIN
WY694646949Medicare PIN