Healthcare Provider Details

I. General information

NPI: 1932642568
Provider Name (Legal Business Name): SAGE ADULT AND GERIATRIC PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 WEBBER ST STE 100
THE DALLES OR
97058-3527
US

IV. Provider business mailing address

1015 WEBBER ST STE 100
THE DALLES OR
97058-3527
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-4804
  • Fax: 541-296-3741
Mailing address:
  • Phone: 541-296-4804
  • Fax: 541-296-3741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number200150061NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number200150060NP
License Number StateOR

VIII. Authorized Official

Name: MS. NINA VAN ES
Title or Position: OWNER
Credential: ANP/GNP
Phone: 541-296-4804