Provider Demographics
NPI:1912901521
Name:NEWSOM, SANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GOODMAN RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1174
Mailing Address - Country:US
Mailing Address - Phone:662-393-8022
Mailing Address - Fax:
Practice Address - Street 1:2906 GOODMAN RD W
Practice Address - Street 2:SUITE 109
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1291
Practice Address - Country:US
Practice Address - Phone:662-393-8022
Practice Address - Fax:662-393-8052
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117535Medicaid
MS512I500595OtherMEDICARE PTAN
MS500000473Medicare PIN
S78544Medicare UPIN