Provider Demographics
NPI:1952424368
Name:SANDOVAL, JOHN ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 HIGHWAY 71 W
Mailing Address - Street 2:SUITE 1150 BLDG 1
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3590
Mailing Address - Country:US
Mailing Address - Phone:512-321-1098
Mailing Address - Fax:512-303-0885
Practice Address - Street 1:815 HIGHWAY 71 W
Practice Address - Street 2:SUITE 1150 BLDG 1
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3590
Practice Address - Country:US
Practice Address - Phone:512-321-1098
Practice Address - Fax:512-303-0885
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1024681OtherNATIONAL CERT NUM
TXPA00581OtherSTATE TX LIC NUM