Provider Demographics
NPI:1376292466
Name:SANDERSON, MICHAEL RYAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 GIBSON ST # B5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1258
Mailing Address - Country:US
Mailing Address - Phone:856-796-2063
Mailing Address - Fax:
Practice Address - Street 1:60 GIBSON ST # B5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02122-1258
Practice Address - Country:US
Practice Address - Phone:856-796-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health