Basic Information
| Provider Information | |||||||||
| NPI: | 1710232699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMBERG | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 MC CUTCHEON RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540167009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153864052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 403 STAGELINE RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540167848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155316800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R 179752-9 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 7900 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.