Provider Demographics
NPI:1871764837
Name:ABBOTT, SANDRA LONG (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LONG
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JAYNE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3030 NORTH STREET
Mailing Address - Street 2:SUITE 560
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1424
Mailing Address - Country:US
Mailing Address - Phone:409-835-9834
Mailing Address - Fax:
Practice Address - Street 1:3030 NORTH STREET
Practice Address - Street 2:SUITE 560
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1424
Practice Address - Country:US
Practice Address - Phone:409-835-9834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX595699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760010407OtherEIN
TXCI5830Medicare PIN
TX00R518Medicare PIN