Provider Demographics
NPI:1558538611
Name:SPOOR-SANDEFUR, CAROL DAWN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:DAWN
Last Name:SPOOR-SANDEFUR
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CHERRY TREE LN.
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-2600
Mailing Address - Country:US
Mailing Address - Phone:315-484-3186
Mailing Address - Fax:518-871-1295
Practice Address - Street 1:171 GOLDENROD LN
Practice Address - Street 2:
Practice Address - City:WARNERS
Practice Address - State:NY
Practice Address - Zip Code:13164-9805
Practice Address - Country:US
Practice Address - Phone:315-299-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000218367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01424235Medicaid
NYR54892Medicare UPIN
NY01424235Medicaid