Basic Information
Provider Information | |||||||||
NPI: | 1598996811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALDAUF-WILCOX | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BALDAUF-WAGNER | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: | F | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972121112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037754931 | ||||||||
FaxNumber: | 5037887285 | ||||||||
Practice Location | |||||||||
Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972121112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037754931 | ||||||||
FaxNumber: | 5037887285 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2009 | ||||||||
LastUpdateDate: | 03/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | 334 | CT | N |   | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 176B00000X |   |   | N |   | Other Service Providers | Midwife |   | 367A00000X | AP60206371 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 367A00000X | 201050221NP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 1598996811 | 05 | WA |   | MEDICAID | 500631551 | 05 | OR |   | MEDICAID |