Provider Demographics
NPI:1730339946
Name:SANDBERG, DARRYL WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:WILLIAM
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:682 HIGH TEA CT
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4631
Mailing Address - Country:US
Mailing Address - Phone:970-485-4377
Mailing Address - Fax:
Practice Address - Street 1:HHC 1/2 AVIATION REGIMENT
Practice Address - Street 2:AVIATION MEDICINE CLINIC BLDG 1058
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-526-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2013-03-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant