Healthcare Provider Details

I. General information

NPI: 1063161255
Provider Name (Legal Business Name): JASON SANDERS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 SIEGEL ST
TAMA IA
52339-2302
US

IV. Provider business mailing address

402 SIEGEL ST
TAMA IA
52339-2302
US

V. Phone/Fax

Practice location:
  • Phone: 641-484-3333
  • Fax: 641-484-3208
Mailing address:
  • Phone: 641-484-3333
  • Fax: 641-484-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA168210
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: