Provider Demographics
NPI:1598013153
Name:SANDOVAL, MARCOS (RN)
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 CHURCHWARD STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1485 GRAEBER STREET
Practice Address - Street 2:BLDG 2300
Practice Address - City:MARCH ARB
Practice Address - State:CA
Practice Address - Zip Code:92518-1728
Practice Address - Country:US
Practice Address - Phone:951-655-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA558975163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency