MEDICARE: PHILIP LERORY SANDERS III FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	44414	WY

General Provider Information

NPI Number	:	1477109445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP LERORY SANDERS III FNP-C

Provider Business Mailing Address
First Line	:	404 ELM ST
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-2571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3236 E GRAND AVE STE D
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5100
Country	:	US
Telephone Number	:	307-760-8602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2019
Last Update Date	:	04/06/2026

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