MEDICARE: SANDRA NEWSOM FNP

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	R852706	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	512I500595	OTHER	MS	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912901521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA NEWSOM FNP

Provider Business Mailing Address
First Line	:	3400 GOODMAN RD W
Second Line	:
City	:	HORN LAKE
State	:	MS
Zip	:	38637-1174
Country	:	US
Telephone Number	:	662-393-8022
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 GOODMAN RD W
Second Line	:	SUITE 109
City	:	HORN LAKE
State	:	MS
Zip	:	38637-1291
Country	:	US
Telephone Number	:	662-393-8022
Fax Number	:	662-393-8052

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/11/2019

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