Healthcare Provider Details

I. General information

NPI: 1063689909
Provider Name (Legal Business Name): LAYNE C. SANDRIDGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 N 64TH DR STE 105A
GLENDALE AZ
85308-7110
US

IV. Provider business mailing address

19801 N 59TH AVE UNIT 11659
GLENDALE AZ
85318-5068
US

V. Phone/Fax

Practice location:
  • Phone: 623-688-5075
  • Fax: 623-688-5075
Mailing address:
  • Phone: 623-688-5075
  • Fax: 623-688-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number40861
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: