Provider Demographics
NPI:1801833165
Name:LERETTE, SANDRA J (PA)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:J
Last Name:LERETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3249
Mailing Address - Country:US
Mailing Address - Phone:269-969-6145
Mailing Address - Fax:269-969-6133
Practice Address - Street 1:632 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3249
Practice Address - Country:US
Practice Address - Phone:269-969-6145
Practice Address - Fax:269-969-6133
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISL004331363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISL004331OtherSTATE LICENSE
MIE93369Medicare UPIN