Provider Demographics
NPI:1770695140
Name:DOCK, SANDRA J (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:DOCK
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 1:170 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2525
Mailing Address - Country:US
Mailing Address - Phone:203-759-3666
Mailing Address - Fax:203-759-3671
Practice Address - Street 1:170 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2525
Practice Address - Country:US
Practice Address - Phone:203-759-3666
Practice Address - Fax:203-759-3671
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P96278Medicare UPIN
970001397Medicare ID - Type Unspecified