Provider Demographics
NPI:1376597658
Name:WOODS, SANDRA A (PAC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:WOODS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:A
Other - Last Name:OTERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF DERMATOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3666
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF DERMATOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002332363A00000X
WI765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP91211Medicare UPIN
MIP31190004Medicare ID - Type UnspecifiedGENESEE COUNTY
MIP31170004Medicare ID - Type UnspecifiedOAKLAND AND WAYNE COUNTY