Provider Demographics
NPI:1023757788
Name:SANDOVAL, MARIA ANGELICA (PA-C)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ANGELICA
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:88 BENJAMIN DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-2240
Mailing Address - Country:US
Mailing Address - Phone:401-297-7027
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant