Provider Demographics
NPI:1386919405
Name:SACK, LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:HIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 E DERENNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6736
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5241
Practice Address - Street 1:16915 HIGHWAY 67 STE A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5819
Practice Address - Country:US
Practice Address - Phone:912-681-2500
Practice Address - Fax:912-681-2025
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134896CMedicaid
GA003134896EMedicaid
GA003134896DMedicaid