Provider Demographics
NPI:1679684823
Name:SANDERS, WILLIAM DAVID (PA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DAVID
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4154 NW TELFAIR GL
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055
Mailing Address - Country:US
Mailing Address - Phone:386-365-0571
Mailing Address - Fax:386-961-8311
Practice Address - Street 1:213 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-961-9809
Practice Address - Fax:386-961-8311
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
E28087Medicare ID - Type Unspecified
S85061Medicare UPIN