Basic Information
| Provider Information | |||||||||
| NPI: | 1932642568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAGE ADULT AND GERIATRIC PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 WEBBER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412964804 | ||||||||
| FaxNumber: | 5412963741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 WEBBER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412964804 | ||||||||
| FaxNumber: | 5412963741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | VAN ES | ||||||||
| AuthorizedOfficialFirstName: | NINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5412964804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | ANP/GNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 200150061NP | OR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 200150060NP | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.