Provider Demographics
NPI:1083881262
Name:HAM, SANDRA K (FNP-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:HAM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W. HESSE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834
Mailing Address - Country:US
Mailing Address - Phone:307-684-1444
Mailing Address - Fax:307-684-0999
Practice Address - Street 1:107 W HESSE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834
Practice Address - Country:US
Practice Address - Phone:307-684-1444
Practice Address - Fax:307-684-0999
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000529363LF0000X
WY23899363LF0000X
WY23899-0963363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYS102619OtherMEDICARE PTAN
WY126725600Medicaid
WY53D2028400OtherCLIA