Provider Demographics
NPI:1104925734
Name:LANDRY, SANDRA C (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:C
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:CLAIRE
Other - Last Name:HUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01050363A00000X
MAPA1865363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110107462AMedicaid
NH3139529Medicaid
AP2993Medicare ID - Type Unspecified