Provider Demographics
NPI:1326115742
Name:SANDOVAL, MARIVEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIVEL
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 REITH WAY
Mailing Address - Street 2:PO BOX 119
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-9521
Mailing Address - Country:US
Mailing Address - Phone:509-837-3933
Mailing Address - Fax:809-837-3885
Practice Address - Street 1:803 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944
Practice Address - Country:US
Practice Address - Phone:509-837-3933
Practice Address - Fax:809-837-3885
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8325193Medicaid
WA50-3908Medicare ID - Type UnspecifiedMARIVEL SANDOVAL MED A#
WAAB18106Medicare ID - Type UnspecifiedMARIVEL SANDOVAL MED B#
WA8325193Medicaid