=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881691905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA L HARTSAW MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 10/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 W LAKEWAY RD STE 1
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82718-6373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-682-7555
-----------------------------------------------------
Fax | 307-687-7243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1272
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82717-1272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-682-7555
-----------------------------------------------------
Fax | 307-687-7243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 4519A
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------