Healthcare Provider Details

I. General information

NPI: 1750802674
Provider Name (Legal Business Name): SARAH WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 SYLVAN LAKE RD STE 210
EAGLE CO
81631-6779
US

IV. Provider business mailing address

PO BOX 4330
AVON CO
81620-4330
US

V. Phone/Fax

Practice location:
  • Phone: 709-266-3409
  • Fax: 970-926-6348
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016093
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0993592
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: