Provider Demographics
NPI:1023070299
Name:MCTAVISH, SANDRA LEE (CNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MCTAVISH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:WHITMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 460
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-232-2002
Mailing Address - Fax:651-232-2031
Practice Address - Street 1:1690 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 460
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3723
Practice Address - Country:US
Practice Address - Phone:651-232-2002
Practice Address - Fax:651-232-2031
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR125328-3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS33789Medicare UPIN