Healthcare Provider Details

I. General information

NPI: 1902450620
Provider Name (Legal Business Name): BRYAN FELIPE SANDOVAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12462 PUTNAM ST
WHITTIER CA
90602-1048
US

IV. Provider business mailing address

8559 SAN JACINTO CT
RANCHO CUCAMONGA CA
91730-4338
US

V. Phone/Fax

Practice location:
  • Phone: 562-789-5429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: