Provider Demographics
NPI:1821742461
Name:SANDOVAL, JESUS EDUARDO
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:EDUARDO
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 1:2529 W CACTUS RD APT 3014
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2588
Mailing Address - Country:US
Mailing Address - Phone:623-853-6282
Mailing Address - Fax:
Practice Address - Street 1:617 N SCOTTSDALE RD STE D
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-4207
Practice Address - Country:US
Practice Address - Phone:480-990-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP054802164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD08258128OtherDRIVER LICENSE NUMBER