Healthcare Provider Details

I. General information

NPI: 1477141190
Provider Name (Legal Business Name): SARAH JO THEIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 TYEE ST
SOLDOTNA AK
99669-7631
US

IV. Provider business mailing address

245 N BINKLEY ST STE 202
SOLDOTNA AK
99669-7500
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4521
  • Fax:
Mailing address:
  • Phone: 907-714-4521
  • Fax: 907-260-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: