Provider Demographics
NPI:1841491917
Name:PAGNUSSAT, SANDRA (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PAGNUSSAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:CRESPO PAGNUSSAT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-876-4449
Mailing Address - Fax:702-252-4906
Practice Address - Street 1:5580 W FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-0111
Practice Address - Country:US
Practice Address - Phone:702-876-4449
Practice Address - Fax:702-252-4906
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN9127390200000X
FLME 112582207RR0500X, 207R00000X, 208000000X, 2080P0216X
NV15845207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGI310ZMedicare Oscar/Certification
NVV110676Medicare PIN