Provider Demographics
NPI:1215042692
Name:FISH, SANDRA CARROLL (RN BSN MS FNPC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:CARROLL
Last Name:FISH
Suffix:
Gender:F
Credentials:RN BSN MS FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ENGLISH AVENUE
Mailing Address - Street 2:PO BOX 515
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-0515
Mailing Address - Country:US
Mailing Address - Phone:315-824-1422
Mailing Address - Fax:
Practice Address - Street 1:1657 SUNSET AVENUE
Practice Address - Street 2:HERITAGE HEALTH CARE CENTER
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-797-7392
Practice Address - Fax:315-797-0836
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S58349Medicare UPIN
RA1904Medicare ID - Type Unspecified