Provider Demographics
NPI:1861433856
Name:JONES, SANDRA L (PAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:JONES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:L
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 PLEASANT AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1440
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2857
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2857
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0111302OtherMEDICA #
MN974764OtherAMERICA'S PPO/ARAZ #
MNDA9041015675OtherPREFERRED ONE #
MN18263OtherNDBS #
MN73A16JOOtherMNBS #
MN122366OtherUCARE #
MN73A14JOOtherMNBS #
MNHP25782OtherHEALTHPARTNERS #
MN18686Medicaid
MN0111301OtherMEDICA #
MN0111303OtherMEDICA #
MN0111301OtherMEDICA #