Provider Demographics
NPI:1528767084
Name:COLLESIDES, SARA (NP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:COLLESIDES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 COUNTY ROUTE 351
Mailing Address - Street 2:
Mailing Address - City:MEDUSA
Mailing Address - State:NY
Mailing Address - Zip Code:12120-1803
Mailing Address - Country:US
Mailing Address - Phone:518-542-3216
Mailing Address - Fax:
Practice Address - Street 1:24 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12051-1305
Practice Address - Country:US
Practice Address - Phone:518-731-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350807363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care