Healthcare Provider Details

I. General information

NPI: 1861621245
Provider Name (Legal Business Name): SARAH RAE DEYO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH R WINE

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 GOODWOOD BLVD STE 202
BATON ROUGE LA
70806-7851
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8013
  • Fax: 225-765-2033
Mailing address:
  • Phone: 225-526-0002
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200274
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: