Provider Demographics
NPI:1013905132
Name:BLANDON, SANDRA (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLANDON
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 1:235 PORT RICHMOND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-876-1732
Mailing Address - Fax:
Practice Address - Street 1:235 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-876-1732
Practice Address - Fax:718-876-3459
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334411363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025685606Medicaid
NYA400008093Medicare PIN
Q23158Medicare UPIN