Healthcare Provider Details

I. General information

NPI: 1144900044
Provider Name (Legal Business Name): SANDRA E AGUAYO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 HIGHWAY 95 STE 105
BULLHEAD CITY AZ
86442-4334
US

IV. Provider business mailing address

3015 HIGHWAY 95 STE 105
BULLHEAD CITY AZ
86442-4334
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-2001
  • Fax: 928-763-2038
Mailing address:
  • Phone: 928-763-2001
  • Fax: 928-763-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11687
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14041377-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: