Basic Information
| Provider Information | |||||||||
| NPI: | 1467981118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HESS | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOBE | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943387 | ||||||||
| FaxNumber: | 4196289501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4463 STATE ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | MINSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458658727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196283821 | ||||||||
| FaxNumber: | 4196289501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.020961 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9934723 | 01 | OH | MEDICARE GROUP PTAN | OTHER | 0105065 | 01 | OH | JTDM FAMILY PRACTICE LLC - GROUP MEDICAID | OTHER | 0229424 | 05 | OH | MEDICAID | 34-1689161 | 01 | OH | JTDM FAMILY PRACTICE LLC - TAX ID | OTHER | H602800 | 01 | OH | MEDICARE PATN | OTHER | 1184652539 | 01 | OH | JTDM FAMILY PRACTICE, LLC GROUP NPI | OTHER |