Provider Demographics
NPI:1750385456
Name:SANDERSON, STEFANIE N (PA-C)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:N
Last Name:SANDERSON
Suffix:
Gender:F
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:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-0502
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-699-4418
Practice Address - Street 1:1545 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6422
Practice Address - Country:US
Practice Address - Phone:817-442-9300
Practice Address - Fax:817-796-0763
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04819363AS0400X, 363AS0400X
IA001369363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP40375Medicare UPIN
IAI4255Medicare ID - Type Unspecified