Provider Demographics
NPI:1821617499
Name:CRUZ, SEBASTIAN ALEJANDRO
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:ALEJANDRO
Last Name:CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NEALY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2023
Mailing Address - Country:US
Mailing Address - Phone:757-764-5788
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2023
Practice Address - Country:US
Practice Address - Phone:740-461-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians