Provider Demographics
NPI:1851510366
Name:MOORE, SANDRA J (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:MOORE
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 1:1425 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-6026
Mailing Address - Country:US
Mailing Address - Phone:320-629-7505
Mailing Address - Fax:320-629-2202
Practice Address - Street 1:1425 MAIN ST N
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-6026
Practice Address - Country:US
Practice Address - Phone:320-629-7505
Practice Address - Fax:320-629-2202
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157868363L00000X
MNR 181983-4363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner