Healthcare Provider Details

I. General information

NPI: 1912095423
Provider Name (Legal Business Name): PAUL SANDERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

4500 STUART STREET, MONCRIEF ARMY HOSPITAL ATTN:MCXL-PQ(CREDENTIALS)
FORT JACKSON SC
29207-5720
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2618
  • Fax: 803-751-2689
Mailing address:
  • Phone: 803-751-2618
  • Fax: 803-751-2689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberNCCPA#1027537
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: