Basic Information
| Provider Information | |||||||||
| NPI: | 1881668408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTLOB | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTEN MEDICAL STAFF SERVICES | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577016000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1420 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056428414 | ||||||||
| FaxNumber: | 6056428618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R029620 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | CP000397 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.