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General NPI Number Information
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NPI Number | 1932642568
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Entity Type | Organization
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Legal Business Name | SAGE ADULT AND GERIATRIC PRIMARY CARE LLC
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Dates
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Enumeration Date | 11/30/2016
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Last Update Date | 11/30/2016
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Provider Practice Location Address
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Address Line | 1015 WEBBER ST STE 100
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City | THE DALLES
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State | OR
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Zip | 97058-3527
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Country | US
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Telephone | 541-296-4804
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Fax | 541-296-3741
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Provider Business Mailing Address
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Address Line | 1015 WEBBER ST STE 100
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City | THE DALLES
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State | OR
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Zip | 97058-3527
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Country | US
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Telephone | 541-296-4804
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Fax | 541-296-3741
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Authorized Official
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Title or Position | OWNER
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Name | MS. NINA VAN ES
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Credential | ANP/GNP
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Telephone | 541-296-4804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 200150061NP
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 200150060NP
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License Number State | OR
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