Healthcare Provider Details

I. General information

NPI: 1780061473
Provider Name (Legal Business Name): ANDREW SASAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 EATON AVE
HAMILTON OH
45013-2767
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 513-867-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: