MEDICARE: TANA SIMS SANDEL PA 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	363A00000X	Physician Assistant	PA 04032	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8Y1431	OTHER	TX	BCBS BILLING NUMBER

General Provider Information

NPI Number	:	1861484370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANA SIMS SANDEL PA C

Provider Business Mailing Address
First Line	:	PO BOX 5500
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75712-5500
Country	:	US
Telephone Number	:	903-324-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 S HENDERSON BLVD
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3566
Country	:	US
Telephone Number	:	903-983-2110
Fax Number	:	903-986-1186

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	05/13/2014

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