Basic Information
Provider Information | |||||||||
NPI: | 1124050299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORNBERGER | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | GAYLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HORNBERGER | ||||||||
OtherFirstName: | S. GAYLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 84888 | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997084888 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9073226355 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1717 W COWLES ST | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997015926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074516682 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 05/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3825 | AK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MD7694 | 05 | AK |   | MEDICAID |