Basic Information
| Provider Information | |||||||||
| NPI: | 1659423309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | C.N.M., ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDANIEL | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | FITZHUGH | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184500 | ||||||||
| FaxNumber: | 5034941678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AP30006157 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 200250014NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1659423309 | 05 | WA | MEDICAID |