1982610036 NPI number — SARA JOAN DIETER PAC

Table of content: SARA JOAN DIETER PAC (NPI 1982610036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982610036 NPI number — SARA JOAN DIETER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETER
Provider First Name:
SARA
Provider Middle Name:
JOAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRADT
Provider Other First Name:
SARA
Provider Other Middle Name:
JOAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982610036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 ANGLERS DR
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
STEAMBOAT SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80487-8836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-871-0000
Provider Business Mailing Address Fax Number:
970-870-1400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 ANGLERS DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
STEAMBOAT SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80487-8836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-871-0000
Provider Business Practice Location Address Fax Number:
970-870-1400
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1480 . This is a "CO STATE LIC" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 81776535 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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