Provider Demographics
NPI:1770005407
Name:SANDERSON, SUZANNE ELLEN (FNP-C)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELLEN
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 E BARNETT RD STE H
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-8000
Mailing Address - Fax:
Practice Address - Street 1:2620 E BARNETT RD STE H
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8383
Practice Address - Country:US
Practice Address - Phone:541-789-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201707770NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily