Provider Demographics
NPI:1083100523
Name:VEGA, SANDRA ALICIA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ALICIA
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:ALICIA
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6601 VALENTINE WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7301
Mailing Address - Country:US
Mailing Address - Phone:505-988-1951
Mailing Address - Fax:505-988-1906
Practice Address - Street 1:6601 VALENTINE WAY
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7301
Practice Address - Country:US
Practice Address - Phone:505-988-1951
Practice Address - Fax:505-988-1906
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator