Healthcare Provider Details

I. General information

NPI: 1710347596
Provider Name (Legal Business Name): SUNRISE ADVANCED PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12274 BANDERA RD SUITE 104
HELOTES TX
78023-4385
US

IV. Provider business mailing address

12274 BANDERA RD SUITE 104
HELOTES TX
78023-4385
US

V. Phone/Fax

Practice location:
  • Phone: 210-780-7248
  • Fax: 210-780-7251
Mailing address:
  • Phone: 210-780-7248
  • Fax: 210-780-7251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: ROBERT PEARSON SANDERS
Title or Position: AUTHORIZED REP/OWNER
Credential: MD
Phone: 210-780-7248