Provider Demographics
NPI:1558377879
Name:SANNER, COLIN CLANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:CLANCY
Last Name:SANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:50 HILLCREST MEDICAL BLVD STE 201
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8954
Practice Address - Country:US
Practice Address - Phone:254-297-0500
Practice Address - Fax:254-297-0506
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4293052084N0400X
NE247092084N0400X
AZ376662084N0400X
TXQ23812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I58282Medicare UPIN