Healthcare Provider Details

I. General information

NPI: 1770079774
Provider Name (Legal Business Name): AUDREY J SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MARSHALL AVE
LONGVIEW TX
75601-5545
US

IV. Provider business mailing address

1500 N RITTER AVE
INDIANAPOLIS IN
46219-3027
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-4880
  • Fax: 903-315-2833
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10002529A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4789
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20376
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: