Provider Demographics
NPI:1821356114
Name:SANDOVAL, LUAR (PA-C)
Entity Type:Individual
Prefix:
First Name:LUAR
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29350 CORAL SEA BLVD BLDG 600
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33039-0001
Mailing Address - Country:US
Mailing Address - Phone:305-988-9123
Mailing Address - Fax:
Practice Address - Street 1:29350 CORAL SEA BLVD BLDG 600
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33039-0001
Practice Address - Country:US
Practice Address - Phone:786-415-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116542261QM1102X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component