Provider Demographics
NPI:1811403876
Name:MEDAKOVICH, SANDRA (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MEDAKOVICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 SHREWSBURY ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4647
Mailing Address - Country:US
Mailing Address - Phone:508-368-7890
Mailing Address - Fax:508-796-8111
Practice Address - Street 1:366 SHREWSBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4647
Practice Address - Country:US
Practice Address - Phone:508-368-7890
Practice Address - Fax:508-796-8111
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-3475363L00000X
IL209.023232363L00000X
WAAP61055169363L00000X
NY345737363LP2300X
MARN2303850363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care