Basic Information
| Provider Information | |||||||||
| NPI: | 1407811151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOTL | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 S IOWA ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | DODGEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535331900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6089353301 | ||||||||
| FaxNumber: | 6089353823 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 S IOWA ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | DODGEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535331900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6089353301 | ||||||||
| FaxNumber: | 6089353853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1770-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1407811151 | 05 | WI | MEDICAID |