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General NPI Number Information
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NPI Number | 1770835415
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Entity Type | Individual
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Provider Name | EMILY BURGESS SANDFORT PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/04/2012
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Last Update Date | 12/28/2021
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Provider Practice Location Address
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Address Line | 835 S VAN BUREN ST
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City | GREEN BAY
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State | WI
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Zip | 54301-3526
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Country | US
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Telephone | 414-294-8828
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Fax |
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Provider Business Mailing Address
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Address Line | 376 CHASE AVE
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City | DE PERE
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State | WI
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Zip | 54115-4071
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Country | US
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Telephone | 414-294-8288
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA173023
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | MA055740
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3100-23
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License Number State | WI
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