Basic Information
| Provider Information | |||||||||
| NPI: | 1780670034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDSTROM | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4401 MASTHEAD ST NE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052437729 | ||||||||
| FaxNumber: | 5052434804 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 N BARTLETT ST | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541662127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155262111 | ||||||||
| FaxNumber: | 7155269166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | RN126117 | TN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | 5845 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | K400174628 | 01 | WI | MEDICARE PTAN | OTHER | K400170079 | 01 | WI | MEDICARE PTAN | OTHER |