Provider Demographics
NPI:1497222400
Name:SANDEFUR, JUSTIN K
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:K
Last Name:SANDEFUR
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 1:4624 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-5484
Mailing Address - Country:US
Mailing Address - Phone:512-748-5404
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-28
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP1394672080P0203X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty