Provider Demographics
NPI:1609504687
Name:SANDER, SEBASTIAN
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:SANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD STE 102B
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3139
Mailing Address - Country:US
Mailing Address - Phone:909-558-2808
Mailing Address - Fax:
Practice Address - Street 1:4311 11TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6367
Practice Address - Country:US
Practice Address - Phone:509-998-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63067363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant