=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437815099
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICK JOEL SANDOVAL NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2021
-----------------------------------------------------
Last Update Date | 07/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 184 WIND CHIME CT STE 103
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-6485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-389-8330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 MYSTIC QUARTZ LN
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540-6460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-281-2480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 5015336
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5015336
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------