Healthcare Provider Details

I. General information

NPI: 1205106887
Provider Name (Legal Business Name): TIARA CATHERINE SAGE PDHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 HIGH SCHOOL RD.
SAINT MARYS AK
99658-0310
US

IV. Provider business mailing address

PO BOX 310
SAINT MARYS AK
99658-0310
US

V. Phone/Fax

Practice location:
  • Phone: 907-438-3500
  • Fax: 907-438-3541
Mailing address:
  • Phone: 907-438-3500
  • Fax: 907-438-3541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: