Provider Demographics
NPI:1831417138
Name:SANDOVAL, JOSE SERGIO (PA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:SERGIO
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2933 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1528
Mailing Address - Country:US
Mailing Address - Phone:323-263-2669
Mailing Address - Fax:323-263-2673
Practice Address - Street 1:2933 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1528
Practice Address - Country:US
Practice Address - Phone:323-263-2669
Practice Address - Fax:323-263-2673
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMS0896146OtherDEA#