Provider Demographics
NPI:1013972371
Name:KWAN, SANDRA M (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:KWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 REID ST # A
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-967-9818
Mailing Address - Fax:253-967-2639
Practice Address - Street 1:9040 REID ST # A
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:253-968-3278
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8210858Medicaid
WA8210858Medicaid
WAG51851Medicare UPIN