Provider Demographics
NPI:1285655266
Name:SANDRIDGE, BRENDA K (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:SANDRIDGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-774-3740
Mailing Address - Fax:336-774-3780
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-774-3740
Practice Address - Fax:336-774-3780
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2013-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC103254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102181Medicaid
NCP48819Medicare UPIN
NCNC3260BMedicare PIN
NC8102181Medicaid