Healthcare Provider Details

I. General information

NPI: 1760966824
Provider Name (Legal Business Name): SIERRA CHURCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIERRA COOK PA-C

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PROFESSIONAL PARK DR SE STE 7
BLACKSBURG VA
24060-6739
US

IV. Provider business mailing address

120 PROFESSIONAL PARK DR SE STE 7
BLACKSBURG VA
24060-6739
US

V. Phone/Fax

Practice location:
  • Phone: 540-443-3832
  • Fax: 540-443-9362
Mailing address:
  • Phone: 540-443-3832
  • Fax: 540-443-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110006397
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: