Provider Demographics
NPI:1104809029
Name:KURSTEDT, SARAH DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:DIANE
Last Name:KURSTEDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CEDAR PT
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2535
Mailing Address - Country:US
Mailing Address - Phone:276-236-9368
Mailing Address - Fax:
Practice Address - Street 1:199 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2454
Practice Address - Country:US
Practice Address - Phone:276-236-6136
Practice Address - Fax:276-236-2536
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-001123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8901171Medicaid
VA008901163Medicaid
VA010014719Medicaid
VA8901171Medicaid
VA000876C86Medicare PIN
P05255Medicare UPIN
VA010014719Medicaid
VA018120C18Medicare PIN
VA000404C63Medicare PIN