Provider Demographics
NPI:1124400791
Name:AVERY, SARA R (PA-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:R
Last Name:AVERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:999 N 92ND ST STE 320
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4875
Mailing Address - Country:US
Mailing Address - Phone:414-266-6550
Mailing Address - Fax:414-266-6579
Practice Address - Street 1:999 N 92ND ST STE 320
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4875
Practice Address - Country:US
Practice Address - Phone:414-266-6550
Practice Address - Fax:414-266-6579
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2018-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI3623-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124400791Medicaid