Basic Information
| Provider Information | |||||||||
| NPI: | 1700938354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028770814 | ||||||||
| FaxNumber: | 7028770113 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028770814 | ||||||||
| FaxNumber: | 7028770113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 12266 | NV | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100512506 | 05 | NV | MEDICAID |