Provider Demographics
NPI:1679666077
Name:SUDERMAN, SANDRA Y (ARNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:Y
Last Name:SUDERMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 SHEIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012-9514
Mailing Address - Country:US
Mailing Address - Phone:913-322-7222
Mailing Address - Fax:913-322-7284
Practice Address - Street 1:913 SHEIDLEY AVE
Practice Address - Street 2:
Practice Address - City:BONNER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66012-9514
Practice Address - Country:US
Practice Address - Phone:913-322-7222
Practice Address - Fax:913-322-7284
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44574363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00101992Medicare ID - Type UnspecifiedRAILROAD
M549923Medicare ID - Type UnspecifiedKANSAS CITY
S83094Medicare UPIN