Provider Demographics
NPI:1427292762
Name:SANDOVAL, MARC JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:JAMES
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 1:1 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0221
Mailing Address - Country:US
Mailing Address - Phone:714-247-0300
Mailing Address - Fax:714-259-1598
Practice Address - Street 1:1100B N TUSTIN AVE # A
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3505
Practice Address - Country:US
Practice Address - Phone:714-247-0300
Practice Address - Fax:714-259-1598
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant