Healthcare Provider Details

I. General information

NPI: 1376804708
Provider Name (Legal Business Name): NICHOLAS RYAN SANDERSFELD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE SUITE 450E
SPOKANE WA
99204-2302
US

IV. Provider business mailing address

PO BOX 421 MICHIGAN STATE UNIVERSITY, DEPT PSYCHIATRY
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-6920
  • Fax:
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9407902
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101020604
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOP60608490
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: