Basic Information
| Provider Information | |||||||||
| NPI: | 1861454555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAGE | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP, RN, MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243520009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 6436 TROUTDALE HWY | ||||||||
| Address2: | |||||||||
| City: | TROUTDALE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243782023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669420401 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001185255 | VA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 0024166932 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 5011292 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5011292 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0024166932 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 5010297 | 01 | NC | LICENSE | OTHER | MS1978824 | 01 | VA | DEA | OTHER | 002354166932 | 01 | VA | NP LICENSE | OTHER | 1033464060 | 05 | VA | MEDICAID |