Provider Demographics
NPI:1689009870
Name:PEREZ, SANDRA M
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:M
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 36TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2143 36TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2103
Practice Address - Country:US
Practice Address - Phone:718-340-9916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1332701174400000X, 390200000X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program