Basic Information
| Provider Information | |||||||||
| NPI: | 1184920407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDLIN | ||||||||
| FirstName: | JANIS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7976 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921670976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032637919 | ||||||||
| FaxNumber: | 3034412388 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 GROSSMONT CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032637919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2011 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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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 | 363AS0400X | PA.0003373 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 52145 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 09771077 | 05 | CO | MEDICAID |