Healthcare Provider Details

I. General information

NPI: 1205985454
Provider Name (Legal Business Name): LORRAINE ROBERTA SANDWICK R-PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MARGARET ST SUITE 100
PLATTSBURGH NY
12901-1874
US

IV. Provider business mailing address

159 MARGARET ST SUITE 100
PLATTSBURGH NY
12901-1874
US

V. Phone/Fax

Practice location:
  • Phone: 518-324-2040
  • Fax: 518-324-2041
Mailing address:
  • Phone: 518-324-2040
  • Fax: 518-324-2041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003126-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: