Provider Demographics
NPI:1154331692
Name:SANDERS, RODNEY (PA)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078-2505
Mailing Address - Country:US
Mailing Address - Phone:478-836-4700
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:HB 64
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-2097
Practice Address - Fax:478-633-7836
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA097396494BMedicaid
GA097396494BMedicaid
GA97WCHDLMedicare ID - Type Unspecified