Healthcare Provider Details

I. General information

NPI: 1396809752
Provider Name (Legal Business Name): TONI MARIE SANDERS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12742 LIMONITE AVE
EASTVALE CA
92880-9630
US

IV. Provider business mailing address

12742 LIMONITE AVE
EASTVALE CA
92880-9630
US

V. Phone/Fax

Practice location:
  • Phone: 951-739-2746
  • Fax: 951-371-6586
Mailing address:
  • Phone: 951-739-2746
  • Fax: 951-371-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 18625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: