Provider Demographics
NPI:1417568809
Name:SANDER, CARRIE VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:VICTORIA
Last Name:SANDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 N EDWARDS ST APT 234
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-2706
Mailing Address - Country:US
Mailing Address - Phone:970-214-6050
Mailing Address - Fax:
Practice Address - Street 1:3600 N GARFIELD ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-6329
Practice Address - Country:US
Practice Address - Phone:432-620-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMPA2022-0105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program