Provider Demographics
NPI:1164508834
Name:SANDUSKY, AMY M (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:SANDUSKY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 PATTERSON RD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1100
Mailing Address - Country:US
Mailing Address - Phone:970-241-0202
Mailing Address - Fax:970-241-0250
Practice Address - Street 1:112 W SPENCER AVE STE A
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2546
Practice Address - Country:US
Practice Address - Phone:970-641-6788
Practice Address - Fax:970-641-0288
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 2025363LF0000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
COQ52202Medicare ID - Type Unspecified