MEDICARE: SANDRA BEYSOLOW

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	363AS0400X	Surgical Physician Assistant	001909	NY

General Provider Information

NPI Number	:	1982017935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA BEYSOLOW

Provider Business Mailing Address
First Line	:	7 KARBE PL
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-4608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 KARBE PL
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-4608
Country	:	US
Telephone Number	:	631-423-4178
Fax Number	:

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

Provider Enumeration Date	:	06/07/2014
Last Update Date	:	06/07/2014

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Directions to “ SANDRA BEYSOLOW ” Practice Location

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