Provider Demographics
NPI:1073872925
Name:SANDOVAL, HERNAN EMILIO (PT)
Entity Type:Individual
Prefix:
First Name:HERNAN
Middle Name:EMILIO
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3146 NW CACHE RD APT 210
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3856
Mailing Address - Country:US
Mailing Address - Phone:580-678-2108
Mailing Address - Fax:
Practice Address - Street 1:3146 NW CACHE RD APT 210
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3856
Practice Address - Country:US
Practice Address - Phone:580-678-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2350225100000X
FL11046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist