Provider Demographics
NPI:1609278597
Name:SAND LAKE CANCER CENTER, PA
Entity Type:Organization
Organization Name:SAND LAKE CANCER CENTER, PA
Other - Org Name:SAND LAKE CANCER CENTER DISPENSARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-351-1002
Mailing Address - Street 1:7301 STONEROCK CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8004
Mailing Address - Country:US
Mailing Address - Phone:407-351-1002
Mailing Address - Fax:407-351-1096
Practice Address - Street 1:7301 STONEROCK CIR STE 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8004
Practice Address - Country:US
Practice Address - Phone:407-351-1002
Practice Address - Fax:407-351-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73340174400000X
FLME76724174400000X
FLME116521174400000X
FLPA9106328363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9074OtherPTAN
FLK9074Medicare PIN