Provider Demographics
NPI:1376739482
Name:SANDOVAL, CHARISE R
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:R
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14803 S AVENIDA CUCANA
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8622
Mailing Address - Country:US
Mailing Address - Phone:520-398-4528
Mailing Address - Fax:
Practice Address - Street 1:14803 S AVENIDA CUCANA
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-8622
Practice Address - Country:US
Practice Address - Phone:520-398-4528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ218323171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ218323OtherAHCCCS PROVIDER