Provider Demographics
NPI:1528342250
Name:SANDOVAL, JUSTINE OFRENEO (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:OFRENEO
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11306 MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3832
Mailing Address - Country:US
Mailing Address - Phone:909-799-2001
Mailing Address - Fax:909-799-2008
Practice Address - Street 1:11306 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3832
Practice Address - Country:US
Practice Address - Phone:909-799-2001
Practice Address - Fax:909-799-2008
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA21795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant