Provider Demographics
NPI:1780718577
Name:SANDERSON, DWIGHT EARL (CRNP)
Entity type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:EARL
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MIFFLINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17059-7852
Mailing Address - Country:US
Mailing Address - Phone:410-913-4659
Mailing Address - Fax:
Practice Address - Street 1:15 WYNTRE BROOKE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4509
Practice Address - Country:US
Practice Address - Phone:717-741-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP001943C363LA2200X
MDR098563363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62031Medicare UPIN