Provider Demographics
NPI:1386195147
Name:KPODO, SANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KPODO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ELKRIDGE LANDING RD FL 2
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1590
Practice Address - Country:US
Practice Address - Phone:410-328-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058427363A00000X
NJ25MP00403200363A00000X
MDC0006661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant