Provider Demographics
NPI:1659643054
Name:SANDERSON, DALE MICHAEL (NP)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:MICHAEL
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:8300 CONSTANTIN BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3489
Practice Address - Country:US
Practice Address - Phone:225-374-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP002754363LN0000X
LAAP06807363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPENDINGOtherBCBS LA
LA2190598Medicaid