Provider Demographics
NPI:1093313959
Name:SANDOVAL, WILIBALDO
Entity Type:Individual
Prefix:
First Name:WILIBALDO
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5262 E VISTA GRANDE
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-6500
Mailing Address - Country:US
Mailing Address - Phone:602-582-9383
Mailing Address - Fax:
Practice Address - Street 1:2451 E BASELINE RD STE 100
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2467
Practice Address - Country:US
Practice Address - Phone:480-304-5152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant