Provider Demographics
NPI:1326217746
Name:MAIDWELL, SANDRA (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MAIDWELL
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1479
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:636 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2668
Practice Address - Country:US
Practice Address - Phone:239-424-3123
Practice Address - Fax:239-424-4041
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006266800Medicaid
FLY05AQOtherBC FLORIDA
FLPA9105482OtherMEDICAL LICENSE
FLY05AQOtherBC FLORIDA