Provider Demographics
NPI:1215917414
Name:SANDY, JAY B (NP)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:B
Last Name:SANDY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2869
Mailing Address - Country:US
Mailing Address - Phone:540-450-0072
Mailing Address - Fax:540-450-0074
Practice Address - Street 1:1818 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2869
Practice Address - Country:US
Practice Address - Phone:540-450-0072
Practice Address - Fax:540-450-0074
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017137339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7102150000Medicaid
VA1215917414Medicaid
VAP00657233OtherMEDICARE RR
VA1215917414Medicaid
WV7102150000Medicaid