=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942890041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA WILSON ELLERBE PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 ST VINCENTS WAY
-----------------------------------------------------
City | MIDDLEBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32068-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-602-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 POWELL ST STE 400
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-1872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9113732
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------