Basic Information
Provider Information | |||||||||
NPI: | 1043695018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ONTIVEROS | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | CHRISTINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 77E THOMAS RD 230 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850123100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025570007 | ||||||||
FaxNumber: | 6025570002 | ||||||||
Practice Location | |||||||||
Address1: | 5750 W THUNDERBIRD RD | ||||||||
Address2: | SUITE B200 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853064660 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6023751700 | ||||||||
FaxNumber: | 6029781225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2015 | ||||||||
LastUpdateDate: | 02/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | AP7841 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 045154 | 05 | AZ |   | MEDICAID |