MEDICARE: SANDRA D FANTAUZZI PAC

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	363A00000X	Physician Assistant	PA9102455	FL

General Provider Information

NPI Number	:	1982684205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA D FANTAUZZI PAC

Provider Business Mailing Address
First Line	:	2285 CORPORATE CIR
Second Line	:	STE 200
City	:	HENDERSON
State	:	NV
Zip	:	89074-7759
Country	:	US
Telephone Number	:	702-360-2763
Fax Number	:	949-783-2880

Provider Business Practice Location Address
First Line	:	4420 SUN N LAKE BLVD
Second Line	:
City	:	SEBRING
State	:	FL
Zip	:	33872-2164
Country	:	US
Telephone Number	:	863-385-1244
Fax Number	:	863-385-6086

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	05/21/2020

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Directions to “ SANDRA D FANTAUZZI PAC” Practice Location

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