Basic Information
| Provider Information | |||||||||
| NPI: | 1861484370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDEL | ||||||||
| FirstName: | TANA | ||||||||
| MiddleName: | SIMS | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5500 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757125500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1718 S HENDERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | KILGORE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756623566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039832110 | ||||||||
| FaxNumber: | 9039861186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 05/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 04032 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8Y1431 | 01 | TX | BCBS BILLING NUMBER | OTHER |