Basic Information
| Provider Information | |||||||||
| NPI: | 1710275425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAVALA | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 3037616278 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CENTRE LAKE DR STE 470 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917611254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095660445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN221556 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0024169503 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | APN.0991802 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 57503737 | 05 | CO | MEDICAID |