Basic Information
| Provider Information | |||||||||
| NPI: | 1275171316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1767 PEARL EYE LN | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417783510 | ||||||||
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| Practice Location | |||||||||
| Address1: | 148 E HERSEY ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975201359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415521111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 201904282RN | OR | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | 201904283NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.