Basic Information
Provider Information | |||||||||
NPI: | 1982710240 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSEN | ||||||||
FirstName: | SONDRA | ||||||||
MiddleName: | SUZETTE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANDERSEN | ||||||||
OtherFirstName: | SAM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 9250 N 3RD ST | ||||||||
Address2: | SUITE 4010 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850202437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026333848 | ||||||||
FaxNumber: | 6026333841 | ||||||||
Practice Location | |||||||||
Address1: | 13555 W MCDOWELL RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | GOODYEAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 853952624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235124176 | ||||||||
FaxNumber: | 6235124199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 10/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3020 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 922733 | 05 | AZ |   | MEDICAID |