Provider Demographics
NPI:1023003688
Name:DACOSTA, SANDRA C (CPNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:C
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 FIELD ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2134
Mailing Address - Country:US
Mailing Address - Phone:508-910-3371
Mailing Address - Fax:508-910-3363
Practice Address - Street 1:225 FIELD ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2134
Practice Address - Country:US
Practice Address - Phone:508-910-3371
Practice Address - Fax:508-910-3363
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252152363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0703567Medicaid
Q43519Medicare UPIN
MANP5017Medicare ID - Type Unspecified