MEDICARE: LUAR SANDOVAL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1102X	Military Outpatient Operational (Transportable) Component Clinic/Center	PA9116542	FL
2	363A00000X	Physician Assistant	PA9116542	FL
3	363A00000X	Physician Assistant	PA17558	TX

General Provider Information

NPI Number	:	1821356114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUAR SANDOVAL PA-C

Provider Business Mailing Address
First Line	:	700 N PEARL ST STE N510
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-2863
Country	:	US
Telephone Number	:	214-580-7277
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 COMMERCE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-7206
Country	:	US
Telephone Number	:	682-610-7900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	08/14/2025

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Directions to “ LUAR SANDOVAL PA-C” Practice Location

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