Healthcare Provider Details

I. General information

NPI: 1356405815
Provider Name (Legal Business Name): SANDRA JO SKIDELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 CENTERVILLE RD
TALLAHASSEE FL
32308-4314
US

IV. Provider business mailing address

1965 CAPITAL CIR NE STE 200
TALLAHASSEE FL
32308-8402
US

V. Phone/Fax

Practice location:
  • Phone: 850-383-3382
  • Fax:
Mailing address:
  • Phone: 850-656-2006
  • Fax: 850-656-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 2697
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: