Basic Information
| Provider Information | |||||||||
| NPI: | 1467426296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALTZMAN | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
| FaxNumber: | 5089097750 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 THOMPSON RD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015701509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089435132 | ||||||||
| FaxNumber: | 5089435209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 226285 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4143933 | 01 | MVP HEALTH CARE | OTHER | AA38452 | 01 | HARVARD PILGRIM HEALTHCRE | OTHER | 0706434 | 01 | MEDICAID/WELFARE | OTHER | 8302745 | 01 | EVERCARE | OTHER | NP5067 | 01 | MEDICARE B | OTHER | 042472266 | 01 | TRICARE CHAMPUS | OTHER | 042472266 | 01 | PRIVATE HLTHCARE SYSTEMS | OTHER | 92685 | 01 | FALLON COMMUNITY HLTH PLN | OTHER | 0706434 | 05 | MA | MEDICAID |