Healthcare Provider Details

I. General information

NPI: 1942890041
Provider Name (Legal Business Name): SARA WILSON ELLERBE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 ST VINCENTS WAY
MIDDLEBURG FL
32068-8447
US

IV. Provider business mailing address

2100 POWELL ST STE 400
EMERYVILLE CA
94608-1872
US

V. Phone/Fax

Practice location:
  • Phone: 904-602-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113732
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: