MEDICARE: SANDRA LYNN CALDWELL

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	363AM0700X	Medical Physician Assistant	PA01376	TX

General Provider Information

NPI Number	:	1659484046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA LYNN CALDWELL

Provider Business Mailing Address
First Line	:	3000 W DAVIS ST
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2036
Country	:	US
Telephone Number	:	936-539-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 W DAVIS ST
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2036
Country	:	US
Telephone Number	:	936-539-9322
Fax Number	:

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	07/08/2007

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