Provider Demographics
NPI:1477547982
Name:BURT, SANDRA JEAN (MSN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:BURT
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:LEITER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:2526 TAYLOR ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3732
Mailing Address - Country:US
Mailing Address - Phone:612-788-6602
Mailing Address - Fax:
Practice Address - Street 1:900 NICOLLET MALL
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2530
Practice Address - Country:US
Practice Address - Phone:612-659-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1088678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640121000Medicaid
MN500003119Medicare PIN