Basic Information
| Provider Information | |||||||||
| NPI: | 1851595342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDALL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2897 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672012897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
| FaxNumber: | 8003747656 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685000 | ||||||||
| FaxNumber: | 3162914272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 07/12/2012 | ||||||||
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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 | 207L00000X | 0535487 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | DO2077 | TN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 0535487 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200869340A | 05 | KS | MEDICAID |