Provider Demographics
NPI:1386018968
Name:MEDINA BOCANGEL, SANDRA (LAC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MEDINA BOCANGEL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 MANCHACA RD
Mailing Address - Street 2:APT 117
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1684
Mailing Address - Country:US
Mailing Address - Phone:512-809-5430
Mailing Address - Fax:
Practice Address - Street 1:4911 MANCHACA RD
Practice Address - Street 2:APT 117
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1684
Practice Address - Country:US
Practice Address - Phone:512-809-5430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01666171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist