Provider Demographics
NPI:1043237910
Name:ROOF, SANDRA K (NP)
Entity Type:Individual
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First Name:SANDRA
Middle Name:K
Last Name:ROOF
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:STE 206
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:920-262-4698
Mailing Address - Fax:920-262-4591
Practice Address - Street 1:111 ANNA ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:WI
Practice Address - Zip Code:53594-1184
Practice Address - Country:US
Practice Address - Phone:920-478-3776
Practice Address - Fax:920-478-3979
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2018-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI733-033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043237910Medicaid
WI43868300Medicaid
WI43868300Medicaid