Healthcare Provider Details

I. General information

NPI: 1437417342
Provider Name (Legal Business Name): LORA J VAN TASSEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORA J PITTMAN M.D.

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 E CHANDLER BLVD STE 110-109
PHOENIX AZ
85048-8702
US

IV. Provider business mailing address

3145 E CHANDLER BLVD STE 110-109
PHOENIX AZ
85048-8702
US

V. Phone/Fax

Practice location:
  • Phone: 602-935-9773
  • Fax:
Mailing address:
  • Phone: 602-935-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number50424
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: