Provider Demographics
NPI:1982855565
Name:HERDER, SANDRA M (APRN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:HERDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROSS BLVD SUITE 2A
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801
Mailing Address - Country:US
Mailing Address - Phone:620-227-3141
Mailing Address - Fax:620-227-8095
Practice Address - Street 1:100 ROSS BLVD SUITE 2A
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801
Practice Address - Country:US
Practice Address - Phone:620-227-3141
Practice Address - Fax:620-227-8095
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1474105061363LF0000X
KS53-44816363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS111190002OtherMEDICARE PTAN
KS200600790BMedicaid