Provider Demographics
NPI:1306518113
Name:SAND PLASTIC SURGERY PLLC
Entity type:Organization
Organization Name:SAND PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:095-324-2980
Mailing Address - Street 1:307 W 6TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2502
Mailing Address - Country:US
Mailing Address - Phone:095-324-2980
Mailing Address - Fax:509-418-9462
Practice Address - Street 1:307 W 6TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2502
Practice Address - Country:US
Practice Address - Phone:509-324-2980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2201492Medicaid