Healthcare Provider Details

I. General information

NPI: 1821587478
Provider Name (Legal Business Name): SARA RAE FISSEL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA RAE KING

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE STE E6
ALBUQUERQUE NM
87102-2645
US

IV. Provider business mailing address

5615 DUNBARTON AVE
PASCO WA
99301-8216
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-1275
  • Fax:
Mailing address:
  • Phone: 877-522-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2023-0045
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: