Healthcare Provider Details

I. General information

NPI: 1225294598
Provider Name (Legal Business Name): KATIE MARIE SAGRERO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

IV. Provider business mailing address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

V. Phone/Fax

Practice location:
  • Phone: 402-502-8846
  • Fax:
Mailing address:
  • Phone: 402-502-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberINTERN - NO LICENSE
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number840
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: