Provider Demographics
NPI:1922628478
Name:SANDOVAL, KHALIL (NP)
Entity type:Individual
Prefix:
First Name:KHALIL
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 JOANNE LOOP UNIT A
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-3894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 WILSHIRE BLVD STE 410
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2915
Practice Address - Country:US
Practice Address - Phone:805-952-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030636363L00000X
TX1001935363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner