Basic Information
| Provider Information | |||||||||
| NPI: | 1902008691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNIEVEL | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1712 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286818570 | ||||||||
| FaxNumber: | 9286818569 | ||||||||
| Practice Location | |||||||||
| Address1: | 1712 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286818570 | ||||||||
| FaxNumber: | 9286818569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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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 | 208100000X | 50035 | MN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0000X | 0101250155 | VA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 833172000 | 05 | MN | MEDICAID |