Provider Demographics
NPI:1023204740
Name:SANDINE, GREGORY W (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:SANDINE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:804-323-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0146407V68Medicare PIN
VA016405V01Medicare PIN
VA016402V21Medicare PIN
VA016406V20Medicare PIN