Provider Demographics
NPI:1346204369
Name:SWANSON, SANDRA L (M D)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:SWANSON
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2145
Mailing Address - Street 2:203 B MOCKSVILLE AVENUE
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-2145
Mailing Address - Country:US
Mailing Address - Phone:704-636-0971
Mailing Address - Fax:704-636-8554
Practice Address - Street 1:203B MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3325
Practice Address - Country:US
Practice Address - Phone:704-636-0971
Practice Address - Fax:704-636-8554
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32440173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC898112BMedicaid
8112BOtherBCBS
070013107OtherRAILROAD MEDICARE
NC898112BMedicaid
2146210DMedicare ID - Type Unspecified