Provider Demographics
NPI:1053908830
Name:RISTAU, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:RISTAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 LIBRARY CIR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6317
Mailing Address - Country:US
Mailing Address - Phone:701-330-8552
Mailing Address - Fax:
Practice Address - Street 1:1405 LIBRARY CIR
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6317
Practice Address - Country:US
Practice Address - Phone:701-330-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND172A00000X, 174400000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND171M00000XMedicaid