Provider Demographics
NPI:1407226038
Name:WIENS, SARA (PA-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WIENS
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 1:24060 CAMINO DEL AVION
Mailing Address - Street 2:STE A
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24060 CAMINO DEL AVION
Practice Address - Street 2:STE A
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629
Practice Address - Country:US
Practice Address - Phone:562-947-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52816363A00000X
CAPA-52816363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant