Provider Demographics
NPI:1356369870
Name:SANDIN, THOMAS SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:SCOTT
Last Name:SANDIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1007 HARBOR HILLS DR STE C
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-8977
Practice Address - Country:US
Practice Address - Phone:906-225-5458
Practice Address - Fax:906-225-1179
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000475A174400000X
MI5601003375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN218420BMedicare ID - Type Unspecified
INP18132Medicare UPIN