Provider Demographics
NPI:1508075250
Name:SANDHAUS, JERRY MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MARK
Last Name:SANDHAUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2514 E PETROGLYPH LN
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-1953
Mailing Address - Country:US
Mailing Address - Phone:210-731-4800
Mailing Address - Fax:
Practice Address - Street 1:2202 N FORBES BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1412
Practice Address - Country:US
Practice Address - Phone:520-872-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01328363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ47260Medicare UPIN