Basic Information
| Provider Information | |||||||||
| NPI: | 1659464683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 5253 | MN | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | HP60939 | 01 | MN | HEALTHPARTNERS | OTHER | 108067 | 01 | MN | UCAREMN | OTHER | 4500160 | 01 | MN | MEDICA | OTHER | 51795 | 05 | ND | MEDICAID |