Provider Demographics
NPI:1396394524
Name:SANDERSON, AVIS A
Entity Type:Individual
Prefix:
First Name:AVIS
Middle Name:A
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 FOUNTAIN AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-2516
Mailing Address - Country:US
Mailing Address - Phone:718-576-3950
Mailing Address - Fax:718-576-3539
Practice Address - Street 1:1 PIERRE POINT PLAZA
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-576-3950
Practice Address - Fax:718-576-3539
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1347674192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY829760448OtherNEW YORK STATE DRIVERS LICENSE