Provider Demographics
NPI:1780670034
Name:SANDSTROM, TONY O (CRNA)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:O
Last Name:SANDSTROM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 MASTHEAD ST NE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4497
Mailing Address - Country:US
Mailing Address - Phone:505-243-7729
Mailing Address - Fax:505-243-4804
Practice Address - Street 1:309 N BARTLETT ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2127
Practice Address - Country:US
Practice Address - Phone:715-526-2111
Practice Address - Fax:715-526-9166
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN126117207L00000X
WI5845367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400174628OtherMEDICARE PTAN
WIK400170079OtherMEDICARE PTAN
WIK400174628OtherMEDICARE PTAN