Basic Information
| Provider Information | |||||||||
| NPI: | 1376566497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | VESTA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 WALTER ST NE STE 501 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057273170 | ||||||||
| FaxNumber: | 5057273171 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 WALTER NE | ||||||||
| Address2: | STE 206 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057272350 | ||||||||
| FaxNumber: | 5057272355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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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 | 207RP1001X | 98330 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 98330 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 98330 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | Z2208 | 05 | NM | MEDICAID |