=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790776102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA BETH SEIFERT PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 KRESGE WAY SUITE 51
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-259-5955
-----------------------------------------------------
Fax | 502-259-5953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 950248
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40295-0248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-489-5730
-----------------------------------------------------
Fax | 502-489-5753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA846
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------