Healthcare Provider Details

I. General information

NPI: 1275852071
Provider Name (Legal Business Name): STEPHANIE ANNE SANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 SANDRIDGE WAY STE 100
LANSDOWNE VA
20176-3689
US

IV. Provider business mailing address

11350 MCCORMICK ROAD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031
US

V. Phone/Fax

Practice location:
  • Phone: 703-738-4344
  • Fax: 703-642-1876
Mailing address:
  • Phone: 410-329-1071
  • Fax: 410-329-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003246
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: