Healthcare Provider Details

I. General information

NPI: 1326217746
Provider Name (Legal Business Name): SANDRA MAIDWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 DEL PRADO BLVD S
CAPE CORAL FL
33990-2668
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-3123
  • Fax: 239-424-4041
Mailing address:
  • Phone: 239-424-1479
  • Fax: 239-424-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: