MEDICARE: SARA GOTTLOB CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R029620	SD
2	363L00000X	Nurse Practitioner	CP000397	SD

General Provider Information

NPI Number	:	1881668408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA GOTTLOB CNP

Provider Business Mailing Address
First Line	:	353 FAIRMONT BLVD
Second Line	:	ATTEN MEDICAL STAFF SERVICES
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 N 10TH ST
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-1532
Country	:	US
Telephone Number	:	605-642-8414
Fax Number	:	605-642-8618

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	02/06/2013

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Directions to “ SARA GOTTLOB CNP” Practice Location

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