=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295966471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA ANNE MOHAGEN DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2009
-----------------------------------------------------
Last Update Date | 10/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1803 S MERIDIAN SUITE A
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-841-3041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 N LAWRENCE ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98406-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-951-2703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 60093440
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------