Provider Demographics
NPI:1316029390
Name:JUSTEN, SANDRA GAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:GAN
Last Name:JUSTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:SY
Other - Last Name:GAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15464 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6149
Practice Address - Country:US
Practice Address - Phone:714-891-9008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 10979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGQ786ZMedicare PIN