Provider Demographics
NPI:1689735581
Name:SANDY, BETH A (CRNP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:SANDY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:EABY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:PCAM , 2 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-662-6681
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:PCAM, 2 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-662-6681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007971363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ10549Medicare UPIN
PA077037Medicare PIN