Provider Demographics
NPI:1821684580
Name:SANDOVAL, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:SANDOVAL
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 1:4361 LATHAM ST STE 270
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4332
Mailing Address - Country:US
Mailing Address - Phone:720-822-3645
Mailing Address - Fax:
Practice Address - Street 1:4361 LATHAM ST STE 270
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4332
Practice Address - Country:US
Practice Address - Phone:720-822-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily