Healthcare Provider Details

I. General information

NPI: 1699050492
Provider Name (Legal Business Name): JOSHUA FITZGERALD SANDEMAN F.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 11/27/2023
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 ATWATER ST N OFC
MONMOUTH OR
97361
US

IV. Provider business mailing address

180 ATWATER ST N OFC
MONMOUTH OR
97361-1801
US

V. Phone/Fax

Practice location:
  • Phone: 503-378-7526
  • Fax: 503-585-4278
Mailing address:
  • Phone: 503-378-7526
  • Fax: 503-585-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: