Healthcare Provider Details

I. General information

NPI: 1861757080
Provider Name (Legal Business Name): KRISTINA LEA SAGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA LEA MALLECK

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHARLESTON RD STE 104
MOUNTAIN VIEW CA
94043-1636
US

IV. Provider business mailing address

3398 S NUCLA WAY
AURORA CO
80013-2021
US

V. Phone/Fax

Practice location:
  • Phone: 408-675-3255
  • Fax: 650-509-3151
Mailing address:
  • Phone: 303-332-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003478
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0003478
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: