Provider Demographics
NPI:1275097420
Name:SANDOVAL, JAMIE D (CNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:D
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5636 RED RIVER RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6094
Mailing Address - Country:US
Mailing Address - Phone:505-934-6628
Mailing Address - Fax:
Practice Address - Street 1:200 EMILIO LOPEZ RD NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6818
Practice Address - Country:US
Practice Address - Phone:505-934-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM55046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily