Provider Demographics
NPI:1932358769
Name:URTISHAK, SANDRA LYNN (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:URTISHAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W. LANCASTER AVE.
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:484-565-1600
Mailing Address - Fax:610-647-2006
Practice Address - Street 1:255 W. LANCASTER AVE.
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:484-565-1600
Practice Address - Fax:610-647-2006
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429886207RH0003X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA152939HK1Medicare PIN
PA1023102840001Medicaid