Healthcare Provider Details

I. General information

NPI: 1730339946
Provider Name (Legal Business Name): DARRYL WILLIAM SANDBERG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HHC 1/2 AVIATION REGIMENT AVIATION MEDICINE CLINIC BLDG 1058
FORT CARSON CO
80913
US

IV. Provider business mailing address

682 HIGH TEA CT
FOUNTAIN CO
80817-4631
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-8477
  • Fax:
Mailing address:
  • Phone: 970-485-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: