Healthcare Provider Details

I. General information

NPI: 1316118219
Provider Name (Legal Business Name): JOHN PATRICK SANDOVAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 SAINT MICHAELS DR
SANTA FE NM
87505-7600
US

IV. Provider business mailing address

720 SAINT MICHAELS DR
SANTA FE NM
87505-7600
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-9402
  • Fax:
Mailing address:
  • Phone: 505-438-9402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2002-0014
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2002-0014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: