MEDICARE: SANDRA PADDOCK CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R 119720-0	MN

General Provider Information

NPI Number	:	1801124565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA PADDOCK CNP

Provider Business Mailing Address
First Line	:	2901 VILLAGE DR
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-1936
Country	:	US
Telephone Number	:	651-428-3345
Fax Number	:	320-255-5634

Provider Business Practice Location Address
First Line	:	1101 LINDEN LN
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-6400
Country	:	US
Telephone Number	:	507-334-0734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	04/26/2018

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