Provider Demographics
NPI:1033855242
Name:SANFORD, NICHOLAS MICHAEL
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 VICTORY AVE APT 250
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4828
Mailing Address - Country:US
Mailing Address - Phone:763-250-0660
Mailing Address - Fax:
Practice Address - Street 1:444 VICTORY AVE APT 250
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4828
Practice Address - Country:US
Practice Address - Phone:763-250-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer