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Individual
SANDRA LODGE
Active
Individual
SANDRA LODGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601003636
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0E01007
BCBSM
MI
01
—
0N67850011
MEDICARE
MI
Enumeration date
03/08/2006
Last updated
10/23/2017
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