Provider Demographics
NPI:1356319842
Name:ARCHER, SANDRA V (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:V
Last Name:ARCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7377
Mailing Address - Fax:801-357-7377
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 110
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7377
Practice Address - Fax:801-357-7377
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2106207V00000X
UT7359472-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1356319842Medicaid
TX145259102Medicaid
TXH47442Medicare UPIN
TX145259102Medicaid
UT1356319842Medicaid