Provider Demographics
NPI:1699882845
Name:BLACK, SARA H (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:H
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LOUISE
Other - Last Name:HENDRIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:4630 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5016
Practice Address - Country:US
Practice Address - Phone:843-357-2299
Practice Address - Fax:843-357-2720
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC776363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1578PAMedicaid
SC9223Medicare PIN