Basic Information
| Provider Information | |||||||||
| NPI: | 1124490370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHASTEEN | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COMMERCE CROSSING | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402292182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534900 | ||||||||
| FaxNumber: | 5024895751 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 BRYAN BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407012781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065281172 | ||||||||
| FaxNumber: | 6065287169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2015 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2069 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01564509 | 01 | KY | RAILROAD MEDICARE | OTHER | 7100387510 | 05 | KY | MEDICAID |