Provider Demographics
NPI:1013999200
Name:WACHTER, SANDRA L (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:WACHTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9383
Mailing Address - Country:US
Mailing Address - Phone:906-249-1379
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3406
Practice Address - Fax:906-225-3094
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704075363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISW075363OtherBLUESHIELD PIN
MI430024329OtherRAILROAD MEDICARE PIN
MI101599640Medicaid
MI101599640Medicaid