Basic Information
Provider Information | |||||||||
NPI: | 1912095423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDERS | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4500 STUART STREET, MONCRIEF ARMY HOSPITAL | ||||||||
Address2: | ATTN:MCXL-PQ(CREDENTIALS) | ||||||||
City: | FORT JACKSON | ||||||||
State: | SC | ||||||||
PostalCode: | 292075720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037512618 | ||||||||
FaxNumber: | 8037512689 | ||||||||
Practice Location | |||||||||
Address1: | 4500 STUART ST | ||||||||
Address2: | MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292075700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037512618 | ||||||||
FaxNumber: | 8037512689 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 171000000X | NCCPA#1027537 |   | Y |   | Other Service Providers | Military Health Care Provider |   |
No ID Information.