Provider Demographics
NPI:1982684205
Name:FANTAUZZI, SANDRA D (PAC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:FANTAUZZI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:4420 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2164
Practice Address - Country:US
Practice Address - Phone:863-385-1244
Practice Address - Fax:863-385-6086
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant