Provider Demographics
NPI:1821042144
Name:SANDBERG, PEGGY A (CRNA)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:CRNA
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 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:FRESNO & R STREET
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-459-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN326621367500000X
CANA2215367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANA0022150OtherBLUE SHIELD OF CA
CARN3266211Medicaid
CARN3266210Medicaid
CANA0022150OtherBLUE SHIELD OF CA
CAZZZ13112ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CARN3266210Medicaid
CARN3266211Medicaid