Basic Information
| Provider Information | |||||||||
| NPI: | 1891944013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATCHA | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | RN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344036 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2008 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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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 | R158456-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1891944013 | 05 | MN | MEDICAID | ENROLLED | 05 | MN | MEDICAID |