Provider Demographics
NPI:1861842072
Name:SANDOVAL, NATHAN PETER (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:PETER
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVENIDA REPUBLICA E6-505 Y ELOY ALFARO
Mailing Address - Street 2:TORRE AQUA, DEPT. 1004
Mailing Address - City:QUITO
Mailing Address - State:PICHINCHA
Mailing Address - Zip Code:170150
Mailing Address - Country:EC
Mailing Address - Phone:099-936-9074
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA REPUBLICA E6-505 Y ELOY ALFARO
Practice Address - Street 2:TORRE AQUA, DEPT. 1004
Practice Address - City:QUITO
Practice Address - State:PICHINCHA
Practice Address - Zip Code:170150
Practice Address - Country:EC
Practice Address - Phone:099-936-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist