Healthcare Provider Details

I. General information

NPI: 1588053664
Provider Name (Legal Business Name): SARA ANNE BOYER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E. 7TH STREET, RM C200 SCHOOL OF PUBLIC HEALTH, INDIANA UNIVERSITY
BLOOMINGTON IN
47405
US

IV. Provider business mailing address

1025 E. 7TH STREET, RM C200 SCHOOL OF PUBLIC HEALTH, INDIANA UNIVERSITY
BLOOMINGTON IN
47405
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-3114
  • Fax: 812-856-2596
Mailing address:
  • Phone: 812-855-3114
  • Fax: 812-856-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number36002176A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: