Provider Demographics
NPI:1750370870
Name:DEFELICE, SANDRA F (PA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:F
Last Name:DEFELICE
Suffix:
Gender:F
Credentials:PA
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 98509
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-9509
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:10101 PARK ROWE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1686
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:225-768-2185
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA20094363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625850Medicaid
LAS67956Medicare UPIN
LA50980P055Medicare PIN