Provider Demographics
NPI:1376725648
Name:TAVISORA, SANDRA CATHERINE (NCTM)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CATHERINE
Last Name:TAVISORA
Suffix:
Gender:F
Credentials:NCTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6961 PUETOLLANO DR
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2339
Mailing Address - Country:US
Mailing Address - Phone:480-650-2010
Mailing Address - Fax:
Practice Address - Street 1:6961 PUETOLLANO DR
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-2339
Practice Address - Country:US
Practice Address - Phone:480-650-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT3113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist