Provider Demographics
NPI:1740264258
Name:SANDERSON, STANTON W (PT)
Entity type:Individual
Prefix:
First Name:STANTON
Middle Name:W
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-2260
Mailing Address - Country:US
Mailing Address - Phone:877-325-2776
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:10566 BRUNSWICK RD
Practice Address - Street 2:#4
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9323
Practice Address - Country:US
Practice Address - Phone:530-273-4152
Practice Address - Fax:530-273-4153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT136941Medicare ID - Type Unspecified