Provider Demographics
NPI:1790864452
Name:ANDERSON, SANDI JEAN
Entity Type:Individual
Prefix:
First Name:SANDI
Middle Name:JEAN
Last Name:ANDERSON
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:PICKERING PLACE
Practice Address - Street 2:1455 11TH AVE NW
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-391-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
27010OtherINTERNAL ID-MOTOR VEHICLE ID
WA1790864452Medicaid
WA0168310OtherL&I
WA1790864452Medicaid
27010OtherINTERNAL ID-MOTOR VEHICLE ID