Provider Demographics
NPI:1598777518
Name:HOOGLAND, SANDRA K (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:HOOGLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SOUTH GIBSON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-2121
Mailing Address - Fax:
Practice Address - Street 1:143 SOUTH GIBSON STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-2121
Practice Address - Fax:715-748-7590
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42937300Medicaid
WIR97868Medicare UPIN
WI001961030Medicare ID - Type Unspecified