Provider Demographics
NPI:1346959798
Name:THEODORE, SANDRO (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SANDRO
Middle Name:
Last Name:THEODORE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11552 BRIGHTON KNOLL LOOP
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2123
Mailing Address - Country:US
Mailing Address - Phone:941-592-9294
Mailing Address - Fax:
Practice Address - Street 1:11552 BRIGHTON KNOLL LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2123
Practice Address - Country:US
Practice Address - Phone:941-592-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant