Provider Demographics
NPI:1710275425
Name:ZAVALA, SANDRA M (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:ZAVALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5562 PHILADELPHIA ST STE 301
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5562 PHILADELPHIA ST STE 301
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2499
Practice Address - Country:US
Practice Address - Phone:909-566-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169503363LF0000X
GARN221556363LF0000X
COAPN.0991802363L00000X
CA95008678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57503737Medicaid
COP01543320Medicare PIN
CO57503737Medicaid
CO421292YQ3LMedicare PIN
GA20250I0969Medicare PIN
CO421292YQN9Medicare PIN