Provider Demographics
NPI:1366615791
Name:ODIASE, SANDRA IMADE (FNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:IMADE
Last Name:ODIASE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:IMADE
Other - Last Name:ODIASE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-860-5422
Practice Address - Street 1:3946 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3300
Practice Address - Country:US
Practice Address - Phone:916-564-0521
Practice Address - Fax:877-860-2907
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17711363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF: 11/13/2014Medicaid
CAP01470028-DV5277OtherRR MEDICARE
CAP01421065 - DS9933OtherRR MEDICARE
CAEFF: 11/13/2014Medicaid
CACA136822Medicare PIN