Basic Information
Provider Information | |||||||||
NPI: | 1922252345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUPPENTHAL | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 449 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 457500449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403744500 | ||||||||
FaxNumber: | 7403745887 | ||||||||
Practice Location | |||||||||
Address1: | 805 FARSON ST STE 117 | ||||||||
Address2: |   | ||||||||
City: | BELPRE | ||||||||
State: | OH | ||||||||
PostalCode: | 457141000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404010033 | ||||||||
FaxNumber: | 7404010039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2008 | ||||||||
LastUpdateDate: | 08/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01389 | WV | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 363AM0700X | 449 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 50.003365 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 0070652 | 05 | OH |   | MEDICAID |