Provider Demographics
NPI:1083648315
Name:PERDEK, SANDRA MACKINNON (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MACKINNON
Last Name:PERDEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MCCLELLAN ST
Mailing Address - Street 2:2 W - MSO
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2425
Practice Address - Country:US
Practice Address - Phone:518-243-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302354363LA2200X
NY333880363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000092603OtherGHI-HMO
NY050806000037OtherFIDELIS CARE
NY788114OtherMVP
NY000490314003OtherBLUE SHIELD
NY7599225OtherGHI-PPO
NYS60984Medicare UPIN
NYRA7464Medicare ID - Type Unspecified