Provider Demographics
NPI:1114910122
Name:YOUNGWORTH, SANDRA J (ANP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:YOUNGWORTH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-6594
Mailing Address - Fax:503-494-5385
Practice Address - Street 1:3303 SW BOND AVE STE 7
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-6594
Practice Address - Fax:503-494-5385
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007006363L00000X
IAH156296363LA2200X
OR200550058NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01543023OtherRR MEDICARE PTAN
WAP01628718OtherRR PTAN CWH
WAP01628718OtherRR PTAN CWH
WAG8939771, G8941534Medicare PIN