Provider Demographics
NPI:1659487627
Name:DE SANDRO, MICHAEL S (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:DE SANDRO
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 24921
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1921
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:903-870-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281974001Medicaid
TX281974003Medicaid
TX281974002Medicaid
TX8N9634OtherBLUECROSS BLUESHIELD
TX281974001Medicaid
TX281974003Medicaid
TXTXB126295Medicare PIN
TXP00292389Medicare PIN
TX8N9634OtherBLUECROSS BLUESHIELD
Q59886Medicare UPIN