Provider Demographics
NPI:1619018918
Name:SANDERS, MARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PA-C
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 1359
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-1359
Mailing Address - Country:US
Mailing Address - Phone:307-212-7708
Mailing Address - Fax:307-352-8148
Practice Address - Street 1:3000 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4202
Practice Address - Country:US
Practice Address - Phone:307-212-7708
Practice Address - Fax:307-352-8148
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY177363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPO8914Medicare UPIN