Provider Demographics
NPI:1104854967
Name:SANDERSON, ALEX JONATHAN (PAC)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JONATHAN
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 EAST WARDELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372
Mailing Address - Country:US
Mailing Address - Phone:910-521-2816
Mailing Address - Fax:910-521-3583
Practice Address - Street 1:307 EAST WARDELL DRIVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372
Practice Address - Country:US
Practice Address - Phone:910-521-2816
Practice Address - Fax:910-521-3583
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2766674BMedicare ID - Type UnspecifiedSOUTH ROBESON MED CTR
NC2766674Medicare ID - Type UnspecifiedJULIAN T PIERCE HEALTH CT
NC2766674CMedicare ID - Type UnspecifiedLUMBERTON HEALTH CTR
NCQ71665Medicare UPIN
NC2766674AMedicare ID - Type UnspecifiedMAXTON MEDICAL CENTER