Provider Demographics
NPI:1851463681
Name:TICE-RASKIN, SANDRA K (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:K
Last Name:TICE-RASKIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:TICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:11795 EDUCATION ST
Practice Address - Street 2:SUITE 100
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-2454
Practice Address - Country:US
Practice Address - Phone:530-886-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80791208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G807910Medicaid
00G807910Medicare ID - Type Unspecified
CA00G807910Medicaid