Healthcare Provider Details

I. General information

NPI: 1265626618
Provider Name (Legal Business Name): JENNIFER M SANDOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2468
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2468
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-2505
  • Fax: 505-298-2985
Mailing address:
  • Phone: 505-298-2505
  • Fax: 505-298-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2007-0018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: