Provider Demographics
NPI:1639860430
Name:BARSOUM, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BARSOUM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 BOLTON DR NW APT 1609
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-9321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2627 W EAU GALLIE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8303
Practice Address - Country:US
Practice Address - Phone:321-505-8659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant