Provider Demographics
NPI:1205985454
Name:SANDWICK, LORRAINE ROBERTA (R-PAC)
Entity type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:ROBERTA
Last Name:SANDWICK
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MARGARET ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1874
Mailing Address - Country:US
Mailing Address - Phone:518-324-2040
Mailing Address - Fax:518-324-2041
Practice Address - Street 1:159 MARGARET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1874
Practice Address - Country:US
Practice Address - Phone:518-324-2040
Practice Address - Fax:518-324-2041
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003126-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743295Medicaid