Provider Demographics
NPI:1124063300
Name:MERTZ, SARA WALLENIUS (A/GNP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:WALLENIUS
Last Name:MERTZ
Suffix:
Gender:F
Credentials:A/GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 BILTMORE AVE STE G276.10
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4601
Mailing Address - Country:US
Mailing Address - Phone:828-213-4502
Mailing Address - Fax:
Practice Address - Street 1:286 OVERLOOK RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-3317
Practice Address - Country:US
Practice Address - Phone:828-213-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950150NP363LA2200X
OR99007553N4363LG0600X
NC5005118363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292676Medicaid
ORRR PTAN 500010228Medicare PIN
S96577Medicare UPIN
ORR108520Medicare PIN
ORR106097Medicare PIN