Basic Information
| Provider Information | |||||||||
| NPI: | 1447579495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2274 HIGHWAY 43 S | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394668141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017983989 | ||||||||
| FaxNumber: | 6017983964 | ||||||||
| Practice Location | |||||||||
| Address1: | 2274 HIGHWAY 43 S | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394668141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017983989 | ||||||||
| FaxNumber: | 6017983964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2010 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R877250 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 09372043 | 05 | MS | MEDICAID | 2130145 | 05 | LA | MEDICAID | 9260512 | 01 | MS | AETNA | OTHER | 12123429 | 01 | MS | CAQH ID NUMBER | OTHER | P00964914 | 01 | MS | RAIL ROAD MEDICARE | OTHER |