Provider Demographics
NPI:1457072910
Name:SANDONA, PETER EDWARD
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:EDWARD
Last Name:SANDONA
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 1:2109 COLEMAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4496
Mailing Address - Country:US
Mailing Address - Phone:360-402-3202
Mailing Address - Fax:
Practice Address - Street 1:514 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-3815
Practice Address - Country:US
Practice Address - Phone:360-249-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61364978390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program