Healthcare Provider Details

I. General information

NPI: 1972320117
Provider Name (Legal Business Name): SAGE MARIE SALACUP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 DEHESA RD
EL CAJON CA
92019-2929
US

IV. Provider business mailing address

4921 DEHESA RD
EL CAJON CA
92019-2929
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-0707
  • Fax: 619-445-0901
Mailing address:
  • Phone: 619-445-0707
  • Fax: 619-445-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: