Provider Demographics
NPI:1770111411
Name:SANFORD, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SEACONET RD
Mailing Address - Street 2:
Mailing Address - City:MATTAPOISETT
Mailing Address - State:MA
Mailing Address - Zip Code:02739-1958
Mailing Address - Country:US
Mailing Address - Phone:978-400-8134
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5491
Practice Address - Country:US
Practice Address - Phone:617-754-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program