Healthcare Provider Details

I. General information

NPI: 1003649096
Provider Name (Legal Business Name): ALEXANDER WADE SANDOVAL RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 RICCO DR
SPARKS NV
89434-6604
US

IV. Provider business mailing address

1056 RICCO DR
SPARKS NV
89434-6604
US

V. Phone/Fax

Practice location:
  • Phone: 775-354-7888
  • Fax:
Mailing address:
  • Phone: 775-354-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN97838
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: