Provider Demographics
NPI:1134728686
Name:GRUBE, SARAH ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:GRUBE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 NICOLLS RD RM 80
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8122
Mailing Address - Country:US
Mailing Address - Phone:631-444-1116
Mailing Address - Fax:631-444-1535
Practice Address - Street 1:100 NICOLLS RD RM 80
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1667
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027609363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program