Healthcare Provider Details

I. General information

NPI: 1780822676
Provider Name (Legal Business Name): SARA MARTELL AICKEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SARA MARTELL

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16528 E DESMET CT
SPOKANE VALLEY WA
99216-3522
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-944-8910
  • Fax: 509-227-7070
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60731140
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTL1398
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1047
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: